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DOCTORA L T H E S I S
Department of Health Sciences Division of Nursing
“Just Deal With It” Health and Social Care Staff´s Perspectives on Changing
Work Routines by Introducing ICT
Perspectives on the Process and Interpretation of Values
Maria Andersson Marchesoni
ISSN 1402-1544ISBN 978-91-7583-280-7 (print)ISBN 978-91-7583-281-4 (pdf)
Luleå University of Technology 2015
Maria A
ndersson Marchesoni “Just D
eal With It”
“Just deal with it”
Health and social care staff´s perspectives on changing
work routines by introducing ICT
Perspectives on the process and interpretation of values
Maria Andersson Marchesoni
Printed by Luleå University of Technology, Graphic Production 2015
ISSN 1402-1544 ISBN 978-91-7583-280-7 (print)ISBN 978-91-7583-281-4 (pdf)
Luleå 2015
www.ltu.se
3
“To recognize the value of care calls into question the structure of values in our society. Care is not a parochial concern of women, a type of secondary moral question, or the work of the least well off in society. Care is a central concern of human life. It is time that we began to change our political and social institution to reflect this truth (Tronto, Joan, 1993, p 180).
To policy-makers and managers in healthcare and social care
Photo: Summer sky of Luleå, August 2014
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TABLE OF CONTENTS
ABSTRACT 1
ORIGINAL PAPERS 2
DEFEINITIONS AND ABBREVIATIONS 3
PREFACE 4
INTRODUCTION 5
BACKGROUND 6
The context of the thesis 6 Care staff in elderly care 7 RN in elderly care 8 Change processes 9 ICT in municipal health and social care 9 Change processes and staff reactions 12
THEORETHICAL FRAMEWORK 13
Caring- and how the concept relates to nursing 13 Values 15 Caring rationality – Technological rationality 16 Feminist ethics of care 17
RATIONALE 20
AIM 21
RESEARCH APPROACH 22
INTRODUCING TO THE RESEARCH CONTEXT 23 FIA project 23 Digital support of medication administration (DSM) 23
METHODS 25 Participants and procedures 25 Data collection 28 Group interviews (paper I & II) 28 Individual interviews (paper III & IV) 29 Analysis 31 Paper I - Latent content analysis 31 Paper II - Phenomenographic analysis 32 Interpretation of Values 32
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Paper III - Interpretive analysis 33 Paper IV – Descriptive and interpretive analysis 34
ETHICS 35 FINDINGS 36
Paper I: Staff expectations on implementing new electronic
applications in a changing organization 36
Paper II: Digital support for medication administration –
A means for reaching the goal of providing good care? 39
Paper III: Going from “paper and pen” to ICT systems –
Elderly care staff’s perspective on managing change processes 41
Paper IV: Technologies in elderly care –
Values in relation to a caring rationality 44
DISCUSSION 47
The life-world perspective 47
Being attentive and present in a practice colonized by ICT systems 48
Management of the change project 51
Needs of confirmation and appreciation 54
METHODOLOGICAL CONSIDERATIONS 55
CONCLUSIONS AND IMPLICATIONS 60
A FINALE REFLECTION 62
TO BE PREVILIGED 64
TACK 66
REFERENCES 69
Paper I
Paper II
Paper III
Paper IV
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ABSTRACT
“Just deal with it”
Health and social care staff´s perspectives on changing work routines by introducing ICT
Perspectives on the process and interpretation of values
”Gilla läget”
Vård-och omsorgspersonals perspektiv på förändrade arbetsrutiner vid införande av IKT
Perspektiv på processen och tolkade värden
Maria Andersson Marchesoni, Division of Nursing, Department of Health Science, Luleå University of Technology, Luleå, Sweden
Policymakers emphasize that the increased use of information and communication technologies (ICT) will improve efficiency and reinforce accountability in health and social care. Care has an intrinsic value that is unquestionable; everyone needs care more or less throughout their life. The two different rationalities, the technical rationality and the caring rationality, raise the question of how technologies can be used in the care sector as a means to support care. The overall aim of this doctoral thesis was to describe and interpret health and social care staff´s expectations, perceptions, experiences and values when changing work routines by introducing ICT. Data was collected through group- and individual interviews with primary health care and social care staff during a research and development (R&D) project. The R&D project aimed at developing work procedures for staff in health and social care by introducing new ICT applications. Data was analyzed with qualitative interpretive approaches. The results showed that expectations from participating staff were overshadowed by earlier development work and they distanced themselves from the R&D project. Staff perceived the ICT solution in relation to utility in their daily practice but also on its impact on the already strained economy and the working environment. Participants experienced unclear decisions and hardly any power of influence in the project. Similar experiences from the past seemed to trigger participants as they were emotional and upset. Once again they experienced low power to influence. Interpreted values showed that staff did not reject technologies per se but they argued for or against the technologies in relation to what they believed would support their view of what good care was. This leads to the conclusion that disturbance-free interactions with the care receiver were prerequisites for accepting any technologies. Furthermore, participants had a wish of taking responsibility in care work and of being confirmed, in an organization with clear visions and management. The caregiving process and its challenges from the perspective of the caregivers need consideration and the concept of caring rationality needs to be put on the agenda. More concern of what good care is and who is defining it should be more investigated and discussed. Change processes in health and social care often focuses on finance and effectiveness. R&D projects and nursing researchers should consider that from a staff perspective it would be beneficial to use approaches where power relations are questioned, and organizations that management should encourage change initiatives from staff Key words: Care, ICT, staff perspectives, values, nursing, individual interviews, group interviews, qualitative interpretive analysis, feminist ethics of care
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ORIGINAL PAPERS
I. Andersson Marchesoni, M., Lindberg, I. & Axelsson, K.(2012) Staff
Expectations on Implementing New Electronic Applications in a
Changing Organization The Health Care Manager, Volume 31, Number 3,
pp. 208–220.
II. Andersson Marchesoni, M., Axelsson, K. & Lindberg, I. (2014) Digital
support for medication administration - A means for reaching the goal of
providing good care? Journal of Health Organization and Management,
Volume 28, Number 3, pp. 327-343.
III. Andersson Marchesoni, M., Axelsson, K., Fältholm, Y. & Lindberg, I. Going from
“paper and pen” to ICT systems. Elderly care staff’s perspective on managing the
change process. Accepted for publication in Informatics for Health and Social Care.
IV. Andersson Marchesoni, M., Axelsson, K., Fältholm, Y. & Lindberg, I.
Technologies in elderly care - values in relation to a caring rationality.
Resubmitted to Nursing Ethics
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DEFEINITIONS AND ABBREVIATIONS
Care staff/ care worker – nurse assistants and enrolled nurses
Care work- is work related to nurse assistants and enrolled nurses
Caregiver- a person that as a profession gives care regardless of any profession. In
this thesis caregiving often relates to care staff.
DN- district nurse
DSM- digital support for medication administration
EN- Enrolled nurses
FGD- focus groups discussion
FGI- focus groups interviews
FIA- framtidens innovativa arbetssätt
FLM- first line managers
ICT- information and communication technologies
NA- nurse assistant
NPM- new public management
Participating staff- is used in the discussion part and excludes FLMs’
RN- registered nurse
Staff- is sometimes used and excludes management perspectives
R&D- research and development project
Technologies- A device to assist medical, social and/or as a support for the care-
receiver or staff. It can be a wheel-chair, a device to measure the care-receivers
level of glucose, or a personal alarm. Technology is also used in general terms and
should be seen as an extension of the self and requires attention. Evelyn Fox Keller
(1985) defines technologies as extensions of the self that not only supports and gives
something, it also require attention.
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PREFACE
When I started my doctoral studies, in the research and development (R&D)
project FIA (Future Innovation for Health and Social Care), I noticed that the
R&D project was built on two assumptions. The first assumption was that the use
of Information and Communication Technology (ICT) to systematize work
routines could improve security and quality in care; secondly that introducing ICT
would make the work attractive to young people and especially to men. ICT in
healthcare and social care was described as having purely beneficial outcomes.
During the project, I also noticed that the representatives from the ICT sector were
the only actors who were expected to define and express the benefits of ICT. These
opinions were supported and legitimatized by political decisions on both the
European and national level.
My interest in the nursing and care workers’ situation in elderly care is built on 20
years of experience working in homecare and elderly care, both as nurse assistant
(NA) and later as registered nurse (RN). Working in elderly care is complex and
demanding in several ways, and does not have the status or the value that it should.
Working as a NA and enrolled nurse (EN) required no education and that
circumstance remains the same. A person without any education in social or
healthcare anyone can still apply for a temporary position and the need for staffing is
increasing.
Administrative tools aimed at enhancing care, many times web based, makes the
work more administrative-intense for both RNs and care staff. These systems are
often tools for controlling and measuring. During these years, I have seen the
development of ICT applications, and also used some supportive ones. But, I have
also seen the opposite, and among that the frustration care staff and RNs sometimes
feel when it comes to handling different, often deficient, time-consuming ICT
systems.
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INTRODUCTION
It seems as if policy-makers have high expectations, and sureness in that, the use of
ICT in healthcare and social care first and foremost is desirable and positively value
laden. ICT will improve efficiency as well as provide smarter, safer and patient-
centred health services. to empower patients and healthcare workers (European
Commission, 2012; Ministry of Health and Social affairs, 2010). According to
politicians, ICT can improve healthcare and social care and increase efficiency, with
fewer persons caring for the increasing number of persons requiring care. Using
standardized support systems for nurses has been shown to embody ideas about
standardisation and quality. However, it has also been shown that patients who do
not fit into the standard might not even know about, or less likely, use the support
system (Fältholm & Jansson, 2008). The arguments of efficiency and quality
improvement are in line with New Public Management’s (NPM’s) vision of
creating cost-saving organizations (Essén, 2003; Ministry of Health and Social
affairs, 2010; Vabø, 2009).
Introducing ICT is a process of mutual transformation: the organization is affected
by the new technology and in turn the technology is inevitably affected by the
specific organizational dynamics (Berg, 2001). The value of allowing nursing,
management, and administrative staff and healthcare assistants to participate in
planning technology change processes is well known (Schraeder, Swamidass, &
Morrison, 2006).
Introducing ICT in municipal elderly and social care, where caregivers routinely
face people’s interdependency and needs of care (Tronto & Fisher, 1990; Tronto,
1993), is complex since caregivers often find themselves dealing with time-
consuming sub-optimized systems. There might be a conflict between two patterns
of structuring and understanding the world – a caring rationality versus a technical
rationality.
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BACKGROUND
The context of the thesis
The number of multiple ill elderly persons, in combination with fewer beds in
acute care settings has, increased the number of persons living at home and in
elderly care facilities with a broad variety of care needs. This lack of resources has
increased demands on municipalities’ ability to provide more advanced care
(Szeshebely, 2000; Trydegård, 2000).
The main goal of municipalities is to provide services and healthcare to people in
need of care so they can live in their homes and look after themselves as long as
possible. Furthermore, care work should provide security and quality care for the
residents based on democratic grounds. Municipalities also have a responsibility to
emancipate and develop the capabilities of individuals, families, and groups. An
older person should have “the ability to live independently in safe conditions and
have an active and meaningful life in the community with others” (SoL 2001:453).
Persons under 65 years of age also have the right to “participate in the society and
to live like others” and the social welfare board is also required to provide
“meaningful employment tailored to his or hers special needs” (SoL2001:453).
Municipalities in Sweden that organize elderly care involve RNs, DNs,
physiotherapists, occupational therapists, and care staff working at different care
facilities or in care-receivers’ ordinary homes. In addition to elderly care,
municipalities are responsible for supporting and housings for disabled persons,
persons with psychiatric diseases, and teenagers with social and family issues and/or
drug addiction. When a person reaches the age of 65, the municipal does not
separate different needs and conditions into different accommodations, persons
within elderly care might have a variety of physical diagnoses, disabilities, and
mental care needs (SoL2001:453).
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The municipal healthcare sector is the largest working sector among women in
Sweden (Ahnlund, 2008, Trydegård, 2000). Most employed within elderly care are
ENs and NAs, followed by RNs and lastly physiotherapists and occupational
therapists (SCB 2013). Elderly care facilities are manned by NAs and ENs 24 hours
a day. RNs are responsible for the nursing care and make medical assessments
supported by physicians working within primary healthcare or the emergency room
at the nearest hospital.
Care staff in elderly care
NAs and ENs meet people with great physical, psychological, and emotional needs.
RNs are also available 24 hours per day, but mostly as consultants being responsible
for many care facilities that are not only within elderly care but also located in a
wide geographical area (Häggström, Mamhidir & Kihlgren, 2010; Kihlgren et al,
2003). NAs and ENs work closely with care-receivers, performing caring needs,
and some of the RNs’ tasks are delegated to NAs and ENs.
Traditionally, the work in home healthcare and in elderly care facilities has been a
practice where the employee was expected to have traits that are strongly connected
to the stereotype of the housewife (Hirdman, 2001; Sörensdotter, 2008).
Historically, the intimate and physical care work has been assigned to people with a
low social status such as slaves, maids, and women (Waerness, 2005). Several studies
(Strömberg, 2004; Sörensdotter, 2008; Twigg, 2004; Wajcman, 1991) have
highlighted that care work has been coded as a feminine practice since it intimately
deals with other people’s bodies.
Work in elderly care is physically hard and demanding (Liaschenko & Peter, 2002;
Wade, 1999), and staff are often dissatisfied with their working conditions (Båvner,
2001; Gustavsson & Szebehely, 2005; Banerjee et al, 2012). Furthermore, stress of
conscience is related to burnout among RNs, ENs, and NAs in municipal elderly
care (Juthberg, 2008). In contrast, the work also gives joy, in receiving hugs or a
smile, and staff expressed strong positive emotions related to contact with residents
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(Häggström et al, 2004). Even if staff were aware of having low status in the
community, they describe their work as important and rewarding (Sandmark et al,
2009). Although having professional pride, they could not recommend the work to
their children (Jansson, Mörtberg & Berg, 2007) and being betrayed from society,
organisation, management and the self was described, as the work had low status,
low salary and broken promises from politicians (Häggström et al, 2004).
RN in elderly care
RNs working in elderly care experience their work as intrinsically rewarding and
also acknowledge that the work offers a degree of creativity; however, they also
recognize that the image of their work (in the media, in the public, and by other
healthcare colleagues) widely devalues their work (Venturato, Kellett, & Windsor,
2006). In elderly care, RNs are keen on guarding the nursing profession’s
superiority in relation to other categories of staff, viewing their competence as of
central value for elderly care (Wreder, 2005). Others confirm the importance of
teamwork in elderly care for the good of the care-receiver (Robben et al, 2012;
Badger et al, 2012; Rurup et al, 2006; Xyrichs & Lowton, 2008)
Ethical concerns for RNs in care of older people are several (Rees, King &
Schmitz, 2009). Among these issues the lack of available physicians to discuss issues
like inadequate pain management, lack of knowledge n palliative care and over or
under treatment (Rees et al, 2009). According to the ethical codes for nurses (ICN,
2012), RNs are responsible for sustaining and collaborating in a respectful way with
co-workers both in nursing and in other fields. Furthermore, the ethical code for
nurses (ICN, 2012) states that nurses can and should be part of creating a positive
practice and environment. Liaschenko and Peter (2004) note that all healthcare
work is relational not only on the level of nurse-patient relationship but also in
terms of what nurses do to facilitate and coordinate care within complex
organizational networks.
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Change processes
The healthcare system is subject to pressures for change that are comparable to
pressures for change in other parts of society. Since1980, Swedish healthcare,
influenced by the private sector, has had major changes of management principles,
changes that originate in New Public Management (NPM) (Trydegård, 2000;
Vabø, 2006; 2009). NPM focuses on efficiency and customer-driven service that
can be measured and evaluated. Concepts have changed, from patients to
clients/customers and from care to service delivery (Berg Jansson, 2009; Trydegård,
2000; Vabø, 2006). Within NPM, there is a strong focus on the customer/client
and mistrust towards professions. This focus has resulted in new actors and the
outsourcing of healthcare. Political decisions have also made clear that ICT is a part
of solving some of the issues, many of them in line with the ideology of NPM –
i.e., productivity, effectiveness, measurable goals, and competitiveness (DS 2002:3;
Ministry of Health and Social affairs, 2010). The rapid adaption of the Swedish
healthcare sector towards values derived from the market has started to raise critical
questions that explore consumerism as the new driving force behind reforms in
healthcare (Vabø, 2006). Furthermore, Blomberg (2008) discusses how
organizations incorporate societal ideals and make these parts of their own structure
and gradually these ideals are taken for granted. Changes in an organization,
however, are never initiated or implemented in a vacuum (Blomberg, 2008).
ICT in municipal health care and social care
The optimistic rhetoric regarding economic savings accentuated by governments
and industry using ICT in health and social care has little or no evidence since the
evidence for cost-savings has rarely been generated through robust economic
evaluations (McLean et al, 2013). Making responsible economic decisions when
resources are scarce is necessary and economic evaluations of ICT in elderly care
have been rare (Vimarlund & Olve, 2005) and) that lack of influence in
organisational decisions for R&D projects might critically affect on-going projects.
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Furthermore, the need to early in a project, openly discuss values and world views
between stakeholders in action research deigned ICT R& D projects.
Communication and interpersonal relationships were found as problematic,
disruptive and time-consuming (Wiig et al, 2014).
The care staff had a positive experience using ICT in municipal healthcare and
social care. Increased security and more freedom of movement was achieved in
dementia care by using monitoring devices (Engström, Ljunggren & Koch, 2009),
although staff still identified technical problems (Hägglund, Scandurra & Koch,
2006; Mariam, 2013). Movement sensors were very sensitive and many false alarms
increased the workload for care assistants. On an organizational level, the electronic
documentation system was not equally implemented throughout the municipal,
creating inconsistently of use (Mariam, 2013). Engström et al (2009); Hägglund,
Scandurra & Koch (2010); Scandurra, Hägglund & Koch (2008); Vimlarund et al
(2008) all used participatory when designing and developing ICT in elderly care. A
design that was understandable by both designers of ICT and professionals was
developed by using structured scenarios during the process of capturing work
situations, needs and expectations (Hägglund et al, 2010). There are advantages
with participatory design, but at the same time they are time-consuming, cost-
intensive and they require active participation of real users (Scandurra et al,
2008).Vimlarund et al (2008) concluded that one issue of importance is to diminish
knowledge asymmetry that exists between practical and technical teams.
A systematic review (Mair et al., 2012) on factors influencing e-health
implementation found that the staff received very little training and information
with regard to “sense-making” (i.e., specifying purpose and benefits). Sense-making
dealt with finding out if users have a shared view of the purpose of the
implemented system, an understanding of how they would be personally affected,
and a grasp of the potential benefits of the system (Mair et al 2012). Similarly, King
et al. (2012) concludes that project management should focus on the stakeholders’
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common understanding and acceptance of project aims and communicate the
visions of the project to those involved.
According to Barakat et al. (2013), when it comes to e-health technologies, there
are gaps in educational and professional developments for staff in home care.
Furthermore, they found that more attention must be paid to the ways in which
technology can be integrated into the working practices and workflow of care
professionals (Barakat et al, 2013). Wälivaara, Andersson and Axelsson (2009) found
that, based on professional reasoning, general practitioners expressed that ICT
should be used with caution as there is evident a risk of misusing ICT (Wälivaara et
al, 2009). Fossum et al. (2011a; 2011b) evaluated the effects and usability of
computerized decision-support systems used in nursing homes to identify pressure
ulcers. They concluded that there were two types of nursing staff: staff comfortable
with computer technology and staff resistant to using computer technology.
Individual barriers included a lack of participation in the implementation process,
lack of computer skills, and lack of motivation (Fossum et al, 2011a).
Sävenstedt, Sandman, and Zingmark (2006) found that staff responsible for elderly
care was ambivalent towards ICT. ICT was described as a promoter of both
humane and inhumane care, with remote control instead of physical meetings. On
the other hand, the ICT had potential to assist with some needs, leading to
increased freedom and less dependency (Sävenstedt et al, 2006). It is possible to
create presence at distance if communication ability of the elderly is good and when
feeling familiar with both the situation and participants in the video meeting
(Sävenstedt, Zingmark & Sandman, 2004). Hedström (2007), however, found that
these values are related to certain actor groups and designing IT systems for elderly
care requires making choices where interests of some actors are included at the
expense of others. Values are involved in the development and diffusion of
technologies and single out stakeholders’ reasons for accepting or rejecting certain
technologies (Hofmann, 2005).
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Jansson, Mörtberg, and Berg (2007) are sceptical when it comes to the expectations
policymakers have of ICT, fearing that they are over-optimistic about the power of
technology. That is, politicians are intrigued by the possibilities technology (e.g.,
ICT) has for well-functioning social care systems; however, care assistants staff, the
people who have the actual experience working with people who need care,
emphasize the importance of caring for people on a face-to-face basis. Jansson
(2007) claims that participatory design is difficult especially as power relations must
be considered when making such decisions. For example, the question “who
decides about the participants’ participation?” sheds light on skewed power
relations. Care workers did not participate in the process, a situation that resulted in
impractical solutions. Furthermore, the process too often was seen from the
technical perspective rather than the social perspective (Berg, Mörtberg & Jansson,
2005; Jansson, 2007). Finally, Hjalmarsson (2009) studied care workers in home
care when a hand-held computer was implemented. The new technology was not
used to support care workers; the management used the technology as a means to
monitor staff. The new technology was also expected to increase the value of the
work for in-home services. This technology, together with the intentions associated
with it, contributed to a double subordination of care workers (Hjalmarsson, 2009).
Change processes and staff reactions
Employees who questioned a change can be seen as having a critical disposition
(Ghaye, 2005). Having a critical disposition means the person is critical thinking,
critical self-reflecting, and a focused toward critical action. It means inwardly
directed reflection that could be uncomfortable (Sumner, 2001). In this context,
being critical is about self and collective thinking and action in the healthcare team.
For these individuals, a critical disposition is a means to awareness of daily practices
and how to improve or perform these practices in the most beneficial way, both for
the elderly and the caregiver.
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Dent, Galloway, & Goldberg (1999) suggest that resistance to change, as a mental
model in organizations, ought to be challenged. People may resist loss of status, loss
of pay, or loss of comfort, but that is not the same as resisting change. That is,
people do not resist change per se. Readiness to accept change among staff is due to
their recognition of the importance of the change as well as to their beliefs of the
organization’s capacity of successfully completing the change (Redfern & Christian,
2003). The amount of insecurity is probably different among individuals and events,
but this insecurity also depends on degree of involvement and participation. Job
satisfaction and organizational commitment also influences how staff perceives
change (Schraeder et al, 2006). Therefore, the reactions to change differ. These
reactions can be facilitated in advance by evaluating the effects of new technologies,
selecting those that provide greater benefits than costs (Baker, 2003).
The management role, especially the manager “in between” with loyalties in
different directions (Carlström, 2012) in the complex constantly- changing
healthcare organizations, poses great challenges. In Sweden, healthcare organizations
value stability and control more than flexibility, an attitude that might influence
change processes (Alharbi et al, 2012).
THEORETICHAL FRAMEWORK
Caring - and how the concept relates to nursing
“Caring is the essence of nursing and the most central and unifying focus for nursing practice”. (Watson, 1988, p 33)
It is my hope that this thesis will contribute to the general scientific knowledge of
the field of nursing, although I have chosen to focus on the concept of care and
caring (care work, care-giving, care-receiver, and feminist care ethics). There are
several reasons for my choice of using caring instead of nursing. Firstly, in the
context of municipal social care and healthcare, the concept of care is the one used
in legal documents (SoL 2001:453), in professional literature, in staff education (in
Swedish; omsorg), and in work descriptions. Lastly, the academic use and concept
14
of nursing is related mainly to the profession of RNs and this thesis includes the
perspectives of many caregiver actors, not just RNs.
The concept of care/caring is part of the concept of nursing and has been used by
nursing theorists (Martinsen, 1989; Sumner, 2001; Watson, 1988; Quinn, 2009).
From a philosophical perspective, care can be described as a deep human action that
belongs to human existence (Martinsen 1989) and human caring is a moral ideal of
nursing (Quinn, 2009). To give and receive care must be stated as a part of daily
life; that is, care is part of the human experience. Care has existed as long as the
human beings have existed.
In my view, nursing both as academic research field and a profession is both more
and less than caring. Care is a universal need, and RNs might not be the only health
care workers who can fulfil caring needs. On the other hand, nursing practice is
more than care in technical terms since nursing practice implies knowledge, for
example, in medicine, technologies, and communication. Even if nursing practice
involves many skills, such as medical, technical, pedagogical, and communicative
ones, it is my view that caring in nursing is a concept of fundamental importance.
Nursing is strongly related to the concept of care and caring, as the caring
perspective emphasizes relationships between the career (the RN or other health
and social care staff) and the care-receiver. Emphasizing the relationship does not
mean that care is only dyadic. Care is not only a matter of someone caring for
another; care is socially and politically situated in a cultural context (Tronto, 1993).
Watson (1988;2003), for example, views caring as a moral ideal that is rooted in our
notions of human dignity and, I posit, this dignity is rooted in an individual, social,
political, and cultural context.
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Values
Values are fundamental to everything we do and are located historically, culturally
and politically. Values are based on basic assumptions that everyone has, and guide
how people think and behave (Ghaye, 2005). Values are means through which
basic assumptions are strengthened or rejected, and persons highly agree that having
exposed values is important, as doing one’s best at work (Gard, 2003). Values deal
with people’s beliefs about how a person should or should not behave, and values
are concepts about good or bad, right and wrong, so it is important to understand
that what we say is not always what we do (Ghaye, 2005; 2008; Badersten,
2003/04). As such, values can be connected to ideals as they express how things
ought to be, and do not necessarily describe a reality or how things actually are.
Furthermore, Ghaye (2008) states that the healthcare team needs to consider
whether what they say (their espoused values) matches their actions (values-in-
action). That is, what one does has more value than what one says, but explicitly
expressing one’s values makes it easier to act in an ethically defensible way. In
addition, the lack of explicitly expressed values makes it harder to have a shared
vision (Ghaye, 2008).
Values are expressed in the professional language of the profession, such as in a
mission statement, in a policy document, and in business and action plans. In daily
interaction with care-receivers, colleagues, and managers, our values are put into
action. Furthermore, Ghaye (2008) states that values are shaped by our religious,
spiritual, ethical, professional, and other beliefs. Values are perspectival; they reflect
something about the particular and shared perspectives we have. These values are
sometimes divided in intrinsic and extrinsic values (Badersten, 2003/2004). Intrinsic
values are good and desirable regardless, they stand independently for something
important and desirable. On the other hand, extrinsic values stand in relation to
something else that is desirable and are sometimes called instrumental values.
Extrinsic values can also be described as means to an end (Badersten, 2003/2004).
16
Caring rationality – Technological rationality
Rationalities help people understand and structure their environments, decide what
they think is the best choice, and structure their everyday life (Alvesson &
Sköldberg, 2008). Rationalities and reasoning stand in relation to a person’s goal
and base of knowledge (Löw, 2013). Feminist theorists, such as Tronto (1993) and
Waerness (1984), share the view that people first and foremost are relational, and
interdependency is acknowledged as one of the basic traits in human life (Waerness,
1984; 1996; Tronto, 1993). This way of understanding the world means that the
everyday problems that caregivers meet require a way of thinking and acting that is
contextual and descriptive, what Waerness (1984) calls a caring rationality. A caring
rationality is based on the assumption that emotions are important and there is no
contradiction between being emotional and rational (Nussbaum, 2001).
Care work first and foremost needs to be organized in a way that it gives the
possibility of flexibility, since care needs change, often rapidly. Prerequisites for the
caring rationality (Waerness, 1996) are acting consciously with empathy, expecting
the care receiver to be irrational and manifesting anxiety. Care is better when the
caregiver has the capacity to really understand the care receiver’s situation and when
the caregiver knows the person they are meeting.
The caring rationality has low value in today’s society since focus on improvement
in general is based on concepts like effectiveness and structuring that can be related
to a technical rationality (Habermas, 1981). Habermas’ (1981) writing on the
colonization of the life-world gives a critical view on the overemphasis of a
technical, or instrumental, rationality in contemporary society. The instrumental
technical rationality (Habermas, 1981) follows the logic of indecency and claims
objectivity, which is linked to economy and power. These systems are a risk for
modern people, since they might deplete what gives meaning and guidance to
processes of socialization. The technical existence is distinguished by impersonal
forces and fragmented impacts since we are confronted with experts on almost
17
everything and this has a negative impact on not only on socialization but also on
personal development (Habermas, 1981).
In my view, there is a push towards a technical rationality into the world where
caring rationalities are and most probably should dominate, and maybe this is
actually the overall ethical conflict to critically examine from the micro and macro
levels in science and society. I also see the question of caring rationality and
technical rationality as important issues to highlight when it comes to participation
in the public debate of equality and democracy.
Feminist ethics of care
Ethics based on the concept of care can help us rethink humans as autonomous by
accepting dependency and human interdependency, a view found in feminist ethics
where care is part of the political agenda (Tronto, 1993; Klaver & Baart, 2011).
According to Tronto (1993), care is a word embedded in our everyday language
and implies reaching out to something other than the self, and as an ideal it is
neither self-referring nor self-absorbing. An ethics of care, according to Tronto
(1993), can and should place care at the centre in on-going societal discourses and
as an ideal in society to ensure a more democratic and pluralistic politics in which
power is more evenly distributed. I agree with this statement and these thoughts are
relevant in this thesis and will be further discussed,
Tronto’s feminist ethics of care is based on four elements: attentiveness,
responsibility, competence, and responsiveness (Tronto, 1993). I have chosen to use
Tronto (1993) as a theoretical frame, since her theory further explains foundations
in the ethics of care with concepts that can be thought of as part of a caring
rationality. Tonto’s (1993) description of the ethics of care is built on her view that
care is both a disposition and most of all a practice. Care requires that someone is
being attentive to needs of care that we care about and recognize that there are needs
to be met. Therefore, the first element is attentiveness, but being attentive to needs is
18
not enough. The next element is responsibility, which includes taking care of,
assuming and determining how to respond to needs of care. Responsibility should
not to be mixed up with formality and obligation. It assumes responsibility for the
identified need and determining how to respond to it. This means recognizing
one’s own capabilities to address unmet needs. Thirdly, the ethics of care involves
competence and actual caregiving. Competence is emphasized as a moral dimension of
an ethics of care. The reason for including competence as a moral dimension of care
is to avoid the bad faith of those who would “take care” of a problem without
being willing to do any form of caregiving. This aspect is relevant in an R& D
project such as the one described in this thesis, as there might be discrepancies
between people who claim good care without actually performing all the four
phases of care according to Tronto (1993).
The fourth element in the ethics of care is responsiveness to given care. This concept
signals an important moral problem within care: care is concerned with conditions
of vulnerability and inequality. To be in a position where one needs care is to be in
a position of some vulnerability. The moral precept of responsiveness requires
remaining alert to the possibilities for abuse that arise with vulnerability. Being
aware or not, abuse of care-receivers and caregivers, as I view it, can be a
consequence of actions on different levels in society and in organisations. Structures
on organizational and societal level, decisions of policy- makers and so forth, are
not excluded. Furthermore, responsiveness also suggests the need to keep a balance
between the needs of caregivers and care-receivers. Responsiveness requires
attentiveness, showing that the moral elements are intertwined. The ethics of care
presented by Tronto (1993) are built on elements of care in practice, and the four
concepts belonging to the theory are intertwined with what she claims are crucial
elements of care in practice.
Good care is normative and the overall goal in the feminist ethics of care require
that the four elements of the theory presented, and phases of the care-process fit
19
together into a whole. Care as a practice involves more than simply good intentions
and that mind-set is highly relevant for participants of this thesis. It requires a deep
and thoughtful knowledge of the situation and of all the actors’ situations, needs,
and competencies. In my view, the four elements of Toronto’s feminist ethics of
care – attentiveness, responsibility, competence, and responsiveness – can make
visible the demanding and complex work of caregivers in this thesis. Tronto (1993)
is in my view a suitable frame to increase an understanding for the complexity in
meeting care needs. In comparison to abstract theories based on justice, principles,
or utilitarianism, the feminist ethics of care presented by Tronto (1993) provides a
relevant perspective on human life and existence especially in care work.
20
RATIONALE
We live in a world of many and rapid changes. The effects changes have on
healthcare and social care, from a caring perspective, still remain important to study.
Inspired by NPM, policymakers have emphasized that increased use of ICT will
support values such as efficiency and reinforce accountability in health and social
care. The emphasis on a technology-based rationality to improve and focus on
efficiency might have a negative impact on the caring rationality.
Depending on the context in which people live and work, it is easy to assume that
ideals and values vary, as they are constructed in interaction between people within
their cultural context. From the normative viewpoint of staff, it can be assumed that
the aspirations and ideals on how to reach the overall goal of good care differ from
the aspirations and ideals of policymakers, the market, and technicians.
Research on attitudes towards change and how staff perceives the use of ICT has
been extensively studied, fewer have focused on meaning and underlying values.
Previous studies show that relatively often staff identified technical and practical
problems, and sometimes unclear goals. Instead of seeing staff’s criticisms as resisting
change, it might be important to investigate how they argue about the change.
With the assumption that good care is a value in the organization that is supported
among staff, this study is an attempt to highlight different perspectives and especially
values during change of work routines. This investigation was done by studying
expectations, perceptions and values during an R&D project that introduced ICT
and as a means for changing and improving work routines.
21
AIM
The overall aim of this doctoral thesis was to describe and interpret health and social
care staff´s expectations, perceptions, experiences, and values when changing work
routines by introducing ICT. This thesis comprises four papers with following
specific aims:
Paper I: To describe staffs’ expectations prior to implementation of new
electronic applications in a changing organization.
Paper II: To describe staffs’ perceptions of digital support for medication
administration (DSM) and out of the perceptions interpret underlying
values.
Paper III: To describe and interpret management experiences during
change processes where ICT was introduced among staff and managers in
elderly care.
Paper IV: To interpret values related to care and technologies connected
to the practice of good care.
22
RESEARCH APPROACH
This doctoral thesis is conducted within the qualitative research paradigm. The four
papers are, in part, interactive, as they have been influenced by circumstances not
under the researchers’ control.
Descriptive, normative, and interpretive approaches were used when analysing
staff’s different perceptions, experiences and values when changing work routines
by introducing ICT. Within the qualitative research paradigm, the reality is not a
fixed entity; it is more about describing how people express their experiences and
how they make sense of their subjective reality and the values they attach to their
subjective reality (Merriam, 2009). Norms and values are inevitable parts of every
step in the research process. Choices have to be made throughout the process and
there is no pure knowledge or truth to be studied as a distant neutral observer in an
objective world (Longino, 1990; Carlheden, 2005). The social world is always
constructed by its members. I agree with Longino (1990) that science is governed
by norms and values that derive from the goal of a research project.
Interactive research (Hartman, 2004) means that the research process in no way is
linear, where one phase is completed before the next begins. This approach means
that research participants, changing conditions, and existing theories are allowed to
affect research. The overall purpose for the research is thus not defined definitely;
rather the data, changing conditions, and new insights from theories are recognized
and deliberately influence further investigations.
23
INTRODUCING TO THE RESEARCH CONTEXT
FIA project
This thesis is part of an R&D project (FIA) carried out in collaboration with ICT
companies, professionals from healthcare and social care within the county council,
and a northern municipal in Sweden together with researchers from Luleå
University of Technology. The R&D project started in 2009 and the intention was
to come up with ICT solutions for the healthcare and social care organizations
involved in the project and to change their working methods. Another belief was
that increased use of ICT would improve the status of care work in society.
Staff involved in the project came from two wards, each ward belonging to two
different elderly care facilities in the municipality – one home care group from
municipal homecare and a primary healthcare centre run by the county council.
The intention was to encourage all employees involved in the project and to
identify their needs in a workshop setting. I took part in these workshops as I
thought it was one way of becoming familiar with the settings and the participants.
One condition in the project was that the identified needs could be met by ICT
solution, since the whole project idea was based on ending up with solutions that
would support the regional growth of ICT companies. In the healthcare centre and
the home care group, different kinds of digital solutions were discussed during the
first data collection. In the municipality, only one solution could be tested during
the project, a digital support for medication administration (DSM) in the elderly
care facilities. The researchers decided to follow the experiences of this test.
Digital support of medication administration (DSM)
One ICT solution could be tested in the FIA project at two wards in elderly care. A
digital tool (smartphone) was wirelessly connected to the patient’s records and
automatically uploaded to their prescriptions (Figure 1). The DSM was aimed at
providing a safe and individual handling of the prescriptions for each person (Table
24
1). The quality of administrating medications was believed to be a positive outcome
of using the DSM. The current routines, using pen and paper to document dosage
and signing when administrating the prescriptions, remained as the DSM was under
development.
Figure 1. Digital support for medication administration (DSM).
With the DSM, RNs’ worked with new software in their offices and on their
computers while care staff at the wards handled the personal digital tool aimed at
replacing the traditional pen and paper registration of the administration of
medications.
Table 1. Functions in the digital support for medication administration (DSM).
Signing every given medication
Reminding when a medication was not administered
Keeping an overview for all residents administrated and not administrated medications within a 24
hour period
Keeping all medications administrated to each person saved and searchable
25
METHODS
Participants and procedures
For all four papers, the participants were selected from the FIA project. At the very
beginning of the FIA project (autumn 2009), before any technologies had been
introduced, staff working at the primary healthcare centre (n = 40) organized under
the county council, and employees in one municipal homecare group (n = 25)
were informed about study I and asked to participate in regard to their expectations
of the project. A total of 23 persons, divided into five groups, participated (Table 2)
in group interviews during the spring 2010. Some of these people had also
participated in the workshops.
In Paper II, all participants were selected from the two wards at the two elderly care
facilities involved in the FIA project. At each ward, nine care staff was employed
and one RN (a total of three) was responsible for the nursing care. At each elderly
care facility, one first line manager (FLM) was responsible for day staff and another
was responsible for night staff; they were also part of the FIA project. In total there
were four FLMs. The technicians led training sessions when the DSM was
introduced and I also attended these sessions. In the autumn 2010, a total of 22
persons divided in five groups took part in the focus group interviews (Table 2). At
this time, the smartphone for medications administration (DSM) was under
development and it was introduced to staff as a future solution, but was not used to
administer medications.
After conducting the two series of interviews with groups, some major
reconstructions in the organization influenced the FIA project. During the time the
R&D project was running, the DNs were about to change organizational affiliation,
from being employed by the county council to being employed by the
municipality. Furthermore, a new legislation called LOV was implemented (SFS
2008:962), opening up private alternatives for healthcare and social care, where the
26
patient provides the right to choose between public and private alternatives, with
the same costs for the patient.
During December 2011 and January 2012, the third data collection was performed
with 13 persons (FLMs, ENs, and NAs) from the two wards at the two elderly care
facilities involved in the FIA project. These individual interviews were used for
Papers III and IV. Since only two FLMs agreed to participate, a second municipality
that was currently introducing an ICT system was contacted for further data
collection. This data collection was performed during fall 2012 for Paper III in a
second nearby municipality that was going through a similar process –
implementation of a new electronic system aimed at planning staff’s work at the
wards in addition to the computer-based documentation.
In the second municipality, a key person was asked to assist in finding FLMs who
had experience of introducing an ICT system and all these FLMs (N= 9) were
asked to participate in study III; four of these agreed to participate (Table 2).
Information about the study was given to the key person via e-mail in August 2012.
The key person then e-mailed the information to all FLMs in the second
municipality along with a request to answer the e-mail if they were interested in
participating. A second set of information was given to each person at the time of
the interviews. Both municipalities were organised in the same way, with a
political-ruled board and financed by taxes.
27
Table 2. The aims, the participants, data collection, and analysis in the four papers.
* 11 of the 12 interviews in paper IV have also been used in paper III. The interview that is not part of paper III out of the 12 interviews in paper IV is left out of the analysis since that person had nothing to add to the question about management in the project and organisation.
Paper Aim Participants Data collection
Analysis
I To describe staff’s expectations prior to implementation of new electronic applications in a changing organization
23 persons from primary healthcare and homecare staff 20 women, 3 men
Spring 2010 Group interviews Autumn 2009 (75-90 min)
Latent qualitative content analysis
II To describe staff’s perceptions of digital support for medication administration (DSM) and out of the perceptions interpret underlying values.
22 persons from municipal elderly care 19 women, 3 men
Focus group interviews Fall 2010 (75-100 min)
Phenomeono-graphy, Normative interpretation of values
III To describe and interpret management experiences during change processes where ICT was introduced among staff and managers in elderly care.
17 persons from municipal elderly care in two municipalities 15 women, 2 men
Individual interviews December 2011- December 2012 (average 80 min)
Interpretive qualitative analysis
IV To interpret values related to care and technologies connected to the practice of good care.
12* persons from municipal elderly care 10 women, 2 men
Individual interviews December 2011-January 2012 (average 80 min)
Content analysis and normative interpretation of values
28
Data collection
To get variation of depth and breadth in the data collection, different interview
techniques were used. Interviews or discussions with groups were used in the initial
part of the project (Paper I and II) to get a variation of expectations and perceptions
and to stimulate discussion since it was early in the R&D project. In the later part,
individual interviews were used to reach a deeper understanding of the staff’s
individual experiences and to ascertain their arguments and reasoning (Papers III
and IV).
At the beginning of the project, and inspired by thoughts in action research, I asked
myself what kind of relationship I wanted to have with participating staff (c.f Herr
& Anderson, 2015). By participating in workshops and the education sessions led by
the technicians, my intention was getting to know expressed needs from
participants, testing the ICT solution and to become familiar with to the possible
subjects for my studies, building a trusting relationship with them. As a researcher, a
good relationship and a balanced distance to the participants is important, so they
feel comfortable enough to openly express their thoughts, arguments, and feelings
in individual interviews.
Group interviews (Papers I and II)
In the interviews with groups, the participants had the opportunity to express and
react to each other’s opinions and stimulate the discussion. These types of
interviews are well suited in an exploratory research design (Redmond & Curtis,
2009). A focus group interview assumes that meaning is interpreted on shared
understandings between participants and therefore focus group interviews belong to
a social constructive paradigm (Dahlin Ivanoff, & Hultberg, 2006). Focus group
interviews are based on communality and shared experiences and can create
awareness among participants. In this group process, the participants make sense of
their experiences and in this their experiences will be modified, leading to
29
construction of new knowledge (Dahlin Ivanoff, & Hultberg, 2006). In Paper I the
questions were explorative and quite unstructured, whereas in Paper II the
questions focused on the specific ICT solution the staff was about to test (Table 3)
and therefore can be labelled semi-structured. The participants were encouraged to
think aloud and were reminded that doubtful or contradictory feelings or
expressions were acceptable.
Table 3. Overview of questions in Papers I and II.
Paper Questions
Paper I
The FIA project, what do you know and think about that?
Tell me, what you know about the on-going project.
Tell me, what can be the benefit of this application or what could be a hindrance?
Which advantages are possible from ICT?
Under what conditions are they good or bad?
Who is going to use these technologies?
Paper II What do you think about the project so far?
Tell me, what do you think about the DSM? And how it will affect your work?
Tell me, what is positive about the digital support or what could be a hindrance?
What are the advantages and disadvantages of the DSM?
Individual interviews (Papers III and IV)
The step to conduct individual interviews (Papers III & IV) was a way of trying to
get deeper and nuanced descriptions to mirror the multiple worlds of the
participants and their subjective way of experiencing and expressing the topic under
inquiry (cf. Kvale and Brinkman, 2012). In qualitative research, the interviewer is
the main tool for the investigation (Kvale and Brinkman, 2012) and the interaction
between the interviewer and the participants highly depends on the interviewer’s
personality and skills (Merriam, 2009). Since I already had met most of participants
30
before conducting individual interviews, I found that they could express their
opinions without hesitation.
The interviews covered questions on technologies (in general and the used ICT
solution in the project – the DSM), care work, and gender (Table 4). The initial
plan was to focus on ICT and technologies, where the technologies affected the
caring relationship. Gender aspects of the work in relation to the concept of care
and technologies were another focus. When starting to read the first transcribed
interview text (done immediately after the interview was conducted), some new
aspects from the experiences of the project came forward. A lot of the participants’
descriptions had to do with what I interpreted as the management of the project,
the lack of clearness, and about feelings of exclusion. In addition, the first two
group interviews included issues dealing with management, so the interviews were
extended to cover the experiences of the management.
Table 4. Overview of open and follow-up questions in the individual interviews.
Questions
How is the process proceeding? To what extent have you been able to have an impact on the change process? What is your experience as FLM to lead changes? Do you get any feedback? What happens with you when you don’t get feedback? How does technology (in general but also the specific solution in the project) change your work? Does technology ease or hinder you in your work? Tell me what caring is for you. Is the relationship towards the care receiver affected by technology? What is challenging in care practice? What education or traits are important in this work? Why is the caring sector (in contrast to the technical sector) dominated by females? Experiences of management.
31
Analysis
All the interviews were recorded but one (where I took notes) and I transcribed
each interview verbatim soon after the performed interview. Before any analysis
started, I thoroughly read the text and distributed the interviews to all authors of
each paper. Throughout the data analysis process, the authors worked closely
together through discussions and the use of step-wise processes (e.g., revision of
grouping processes).
At the beginning of the project and until the end of 2011, written notes and
narratives were done after group interviews, information meetings, and educational
meetings. Although I explicitly never used these notes in the analysis, it is important
to be aware that the observations and reflections I made and recorded might have
influenced the analysis. The papers in this thesis are descriptive and interpretive.
The intention was to illuminate how the participants constructed their realities
within their specific context and in interaction with others.
Paper I - Latent content analysis
Latent qualitative content analysis inspired by Woods and Catanzaro (1988) is
concerned with meaning that can be identified in passages of a text and was used to
analyse the transcribed text from the first group interviews. The five interviews
were considered as one unit to analyse. The text was sorted in the areas of
discussions, which were different from the areas in the interview guide, and no
theoretical frame was used for the interview guide. The three identified areas were
then analysed and sorted in eleven dimensions. Each area and dimension were then
compared and discussed. The first author wrote a diary of thoughts, questions,
interpretations, and reflections during the whole process, which were also discussed
and were a base for interpretations. The reflective and interpretive process can be
seen as hermeneutic, as it was from small parts of the text and specific content to a
wider sense of the whole, gaining a deeper understanding of the data. This process
was facilitated by trying to understand organizational circumstances that might have
32
influenced the participants’ discussions. One overall theme was identified as the
result of this process.
Paper II - Phenomenographic analysis
A phenomenographic analysis (Dahlgren & Fallsberg, 1991) was used to analyse the
focus group interviews in the municipality context. Phenomenography intends to
uncover the many ways that people perceive or conceptualize a specific
phenomenon rather than to uncover a specific phenomenon. An important aspect
of this methodology is what Marton (1981) calls the first or the second order
perspectives. Applying the first order perspective means an attempt to capture and
describe the real essence of a phenomenon. Applying the second order perspective
has to do with how the phenomenon is perceived.
After reading the texts, all statements that contained perceptions about the DSM
were identified and compared to identify similarities and differences. Statements
appearing to be similar in regard to what they were talking about in relation to the
aim of the study were grouped together. A preliminary description of the essence of
the grouped text was made. The next step was to compare preliminary descriptive
categories with regard to similarities and differences and then construct a final
suitable linguistic expression for each group of text (cf. Dahlgren & Fallsberg, 1991).
This resulted in three main descriptive categories with three variations of content
for each category.
Interpretation of values
Based on the type of data and the way participants expressed how they perceived
the DSM, we looked at the pattern of argumentation for or against the DSM. The
arguments were logical and sometimes with explicit reasons for different
standpoints.
To understand the participants’ arguments about the DSM, we decided that Paper
II would benefit by taking the analysis one step further. Inspired by Badersten
33
(2006) and normative methodology, the analysis identified underlying values and
highlighted arguments used by participants if and when they made an opinion about
the efficacy of DSM. A normative analysis is a way of studying what is desirable and
depends on what values are guarded or hidden and what people value depends on
contextual factors. Values are not stable or fixed but socially and culturally
constructed. Reflective notes that were written by the first author during the
phenomenographic analysis were read and discussed by the three authors of Paper II
to facilitate the process of interpreting underlying values. The authors’ pre-
understandings as nurses and researchers were also discussed.
Paper III- Interpretive analysis
A qualitative interpretive method inspired by Charmaz (2006) and Alvesson and
Sköldberg (2008) were used to analyse the data in Paper III. We marked text where
the interviewee focused on the management of the process, decisions, purpose, and
lack of clearness from management on different levels (FLM, politicians, or higher
up in the organization). These opinions were then used for the analysis. A short
summary of the marked parts was written on each transcribed interview. The
method used gives possibilities to look at both what was said and how things were
said. The how aspect of the data was also used as a base for interpretation. Text was
then coded into smaller units. Next, data were grouped according to content in the
text units. At this point in the analysis, the two different perspectives in the
interviews (i.e., FLM and care staff) were discussed. The care staff and FLM
participants had many similar expressions/descriptions, so in the results we decided
to separate only those parts that differed. The grouping process with revising and
regrouping of the data continued until a consensus of themes could be reached
among all authors. The final five themes were then reviewed to see how they
related to each other and mirrored the process described by the participants.
34
Paper IV Descriptive and interpretive analysis
In Paper IV, a qualitative descriptive and interpretive analysis was chosen, starting
with a latent content analysis (cf. Woods & Catanzaro, 1988) and proceeded with a
normative approach to interpret values (cf. Badersten, 2003/04; 2006). Using a
normative approach makes it possible to study how something ought to be in
contrast to how something actually is. In this paper, the normative approach was
used as a tool when looking at the data with the intention of interpreting the values
underpinning the reasoning and arguments used among staff when providing care.
These arguments are a way of claiming the good or bad aspects about something
(i.e., taking a stand for or against a claim) (Badersten, 2003/04; 2006). The main
topic is the underlying assumption that people use arguments that are grounded in
values to reach an overall goal and therefore an intrinsic value always lies at the base
of argumentation (Badersten 2003/04).
The latent content analysis started with all interviews being read with a focus on the
caregivers’ expressions and how they gave voice to their work in relation to care
and technologies. Expressions about care and technologies were organized from the
interviews and this text was used as one unit to analyse. The text was divided into
text units that were assigned an identification code to facilitate the process of going
back and forth during the analysis. These text units were then re-read with the
intent of clustering and condensing the text.
In the normative approach, the clustered text units were read with a focus on
interpreting what value the caregiver was advocating. This process was facilitated by
posing two questions while reading the texts: “What are they arguing for and what
do they desire?” and “What are they striving towards and what is considered good
or desirable?” The authors of Paper IV independently read parts of the data and
independently identified values, which were compared and discussed. The grouped
and condensed text units were formulated as arguments supporting each value. The
35
individual reflections, collaboratively made among the authors followed by
discussions, were crucial in labelling the final four interpreted values.
ETHICS
In all fours studies, we viewed the participants not only as objects to be studied but
also as thinking and feeling persons with the opportunity to influence the process
(cf. Hartman, 2004). Furthermore, my own understanding of complex
organizational changes in healthcare and my own experience working as both a NA
and RN made it easy for me early in the R&D project to decide that I would let
the changing conditions in the project influence the four studies that are part of this
thesis. Despite this, it was important to keep in mind that a research interview is
never a conversation on equal terms and as a researcher careful attention to these
circumstances needs to be taken (Forsberg, 2002).
I tried to make the situation as clear as possible by informing the participants about
the study in written form and verbally. They were informed that participation in
the study was voluntary, that they could drop out at any time without giving any
explanation, and that their identity would not be revealed. They were also
informed that the recorded interviews were kept in a locked cabinet. Before each
interview, I reminded the participants about the researcher’s role in the project and
that it was not to be mixed up with project leaders’ or technicians’ roles. The
participants were reminded before each interview that they could stop the interview
at any time and that they could drop out at any time without explanation. Most
participants did not seem to feel any discomfort during the interviews and all except
one had no problems with being recorded, and during that individual interview I
took notes instead of recording it. Interview texts shared among the authors did not
identify participants by name but by group and job (e.g., group 1, RN). All papers
in this study were given approval from The Regional Ethical Review Board in
Umeå, Sweden (Dnr 09-209M, 2009-1414-31).
36
FINDINGS
Findings from the studies in Papers I-IV are presented separately. The aim in Paper
I was to describe staff‘s expectations prior to implementation of new electronic
applications in a changing organization. The aim in Paper II was to describe staff’s
perceptions of digital support for medication administration (DSM) and out of
perceptions interpret underlying values. In Paper III, the aim was to describe and
interpret management experiences during change processes where ICT was
introduced among staff and managers in elderly care. In Paper IV, the aim was to
interpret values related to care and technologies connected to the practice of good
care.
Paper I: Staff expectations on implementing new electronic applications
in a changing organization
In Paper I, a theme was identified: “Taking a standpoint today in relation to the
past”. This theme emerged from areas of discussion: “distance holding”, “ruled by
the organization”, and “healthcare development in the future” (Table 5).
Table 5. Staff’s expectations prior to implementation of new electronic applications in a changing organization
Distance holding Ruled by the organization Healthcare development in
the future
This does not involve me
To be forced into new systems
Striving for efficiency
Not seeing any benefit of the changes
The person’s will of taking responsibility
Looking at the coming changes with some curiosity
The others, not us Technology contra being near
Creating new needs for increased healthcare consumption
Border between organisations will still remain
New demands on staff to manage
37
The theme reveals that participants’ statements were influenced by past experience
with changes and they related the on-going project or, the project’s outcomes
relative to these experiences. One way of dealing with the project was found in the
first area of discussion, “distance holding”. Participants acted with a certain distance
to the project and did not seem to commit themselves much with the changes,
which were unfamiliar to them. Distance holding included discussions about the
purpose of the project and missing information from the organization's leadership.
In addition, this distancing was reflected in the belief that the participants often felt
that others, rather than themselves, would benefit from electronic applications at
work.
The second area of discussion was “ruled by the organization”. The participants
described how they felt forced to work with systems – such as ICT systems and
laws and regulations – that they sometimes found an obstacle in their work.
Participants feared that increased use of electronic systems could actually keep their
charges from receiving the proper healthcare, as the attention these systems require
could compete for the attention patients require. They expressed a possibility that
healthcare governed by overly systematic policies could compromise their
professional ability to meet the needs of their patients. In addition, they expressed a
desire to take responsibility for individual and unpredictable events, efforts that they
felt such systematic policies would inhibit. The border between the organizations
was considered a huge issue to be solved since it made work bureaucratic and they
believed a small project like FIA could not change these issues. It was not
considered desirable to work in an organization where the employee worked solely
on the basis of the motto “to follow the rules”.
In the discussions about “healthcare development in the future” the participants
stated that healthcare is by no means a protected zone from the general trends that
exist in society. The participants mentioned concepts such as efficiency,
consumption, and creating needs. Participants expressed curiosity for the future
development and identified some interesting challenges with the new direction in
38
healthcare, as they thought that future staff would be forced to be more innovative
in how they work. A great focus in the discussions regarded how the LOV
(Freedom of Choice in Health Care) was actually connected to projects like the one
they were currently involved in. Participants expressed how they understood that
there were strong links to the project between consumption and competiveness
between the health centres, which was a consequence of LOV. The participants
drew parallels with developments in the rest of society, with longer opening hours
in supermarkets and gas stations and the new focus among healthcare centres to “get
elected" by their patients. They mentioned that there was a risk that even the public
healthcare system would become too market-oriented and not provide care to the
person most in need of it. Increased demands from society and care receivers would
also lead to increased demands on pedagogical skills among healthcare staff.
39
Paper II: Digital support for medication administration – A means for
reaching the goal of providing good care?
In Paper II, the analysis resulted in three descriptive categories: “utility”, “impact
on working environment”, and “economic impact” (Table 6). Based on the
manifest content of the categories, we interpreted the following values: “benefits”,
“good working environment” and “good economy”. In this phase of the project,
participants could relate their perceptions to a specific technical application, the
DSM, and a specific work procedure, namely the medication administration
process.
Table 6. Descriptive categories of staff’s different ways of perceiving the digital support for medication administration (DSM) and variation of content in each category. Categories Utility Impact on working
environment Economic impact
Variation of
content
User-friendly or not
Communication and relations improved and not
Economic burden for the municipality
Increased quality and statistics Needed or not
Increased stress Exclusion and status
Companies will make money We will not become more efficient
Values Benefits Good working environment
Good economy
Participants focused much of their discussion on the “utility” of the DSM and if it
was considered user-friendly or not. The participants strongly emphasized that any
solution had to be less time-consuming than the existing ways of performing
medication administration. The participants thought that reducing the number of
missed medications could be an improvement. This opinion was held by night staff
and related to the fact that much of their work is done in isolation, without the
benefit of colleagues. They could see that the quality of medications would increase
in general as they had an easy overview of who had received medication without
needing to call or search for a colleague. Interestingly, a majority of the participants
40
did not recognize that administering medications was an issue that needed to
improve.
The “impact of working environment” was also an area of great interest to the
participants. Participants saw the value in continuing to have face-to-face
communication with each other and other professionals, as it was faster and less
problematic. Using technology, such as mobile phones or e-mails, was considered
time-consuming and could contribute to a misunderstanding in communication.
Participants thought the amount of alarms would stress them, since they already
carried a tool that notified them when a care receiver needed their attention. The
fact that the electronic application would remind them when they did something
wrong contributed to the general feeling of rarely being seen or valued in their
work, but always reminded when they were doing something wrong. Participants’
descriptions of being excluded from the project were part of the discussions. They
did not feel that anyone listened to their opinions, even if they were asked to have
one. In addition, they did not feel that they had been given that much information
about the motives behind the project.
Participants showed great concern of the “economic impact” that the DSM could
have on municipalities, since they were well aware that it was already financially
strained. This was also a repeated message from the organization’s management.
The participants did not understand how electronic support for medication
administration could possibly reduce costs for the municipality. Additionally, they
discussed and tried to work out how and if this tool in any way could reduce the
number of staff, because they regarded cutting down on staffing as the only way for
the municipality to save money. Participants did not see how the DSM would make
them become more efficient in work or that the municipality could in any way
reduce staffing due to the use of the DSM. Instead, they thought that the companies
that produced the DSM would have be the only ones who received an advantage,
an economic advantage.
41
Interpreting underlying values was a step in the analysis which came out of
awareness that participants used arguments during the FGI in relation to whether to
accept or reject the DSM. The interpretation of this was by done asking the
following two questions of the data: 1.) How does staff perceive and form an
opinion of the electronic application? 2.) What is desirable and what values are
guarded, or not, when they argue? Three extrinsic values were identified to be
desirable: good economy, a good working environment, and benefits. All values
were seen as a prerequisite for achieving good care, which was also interpreted as an
intrinsic value. Good care was interpreted as an overall value. When arguing for or
against the DSM, the DSM had to support the means (the extrinsic values) for
reaching the goal of providing good care.
Paper III: Going from “paper and pen” to ICT systems - Elderly care
staff perspective on managing the change process
The analysis in Paper III resulted in five themes: “clear focus - unclear process”;
“first line managers receiving a system of support”; “low power to influence”; “low
confirmation”; and “reciprocal understanding”(Table 7).
Table 7. Interpreted themes (no. 5)
“Clear focus – unclear process” showed that the focus on ICT seemed clear to
participants, but the process of the project was not. FLMs expressed that they were
not involved in the development project and missed information about on-going
Themes
Clear focus – unclear process
First line managers receiving a system of support
Low power to influence
Low confirmation
Reciprocal understanding
42
activities. Participants’ expressions about the on-going changes altered as they talked
about the change process from its very beginning until becoming aware of the lack
of clearness. There were criticisms about lack of good communication during the
change process and the handling of the development work. “First line managers
receiving a system of support” gives a picture of the FLM as not playing an active
part in the projects, as they received a tool and not actively asked for. Still, the FLMs
seemed content about the ICT systems, and they thought systems could support
their work. They believed that the new system for scheduling staff’s work would
have a positive impact on some psychosocial problems among staff. In some way,
the vision of how the ICT system would support the FLMs’ roles was described as
an implicit self-critique of the lack of capabilities to solve some problematic issues at
the wards. It was clear that FLMs had not come up with the idea of using ICT to
solve these psychosocial issues; they were more passive receivers.
Participants believed that they had “low power to influence” in the projects, they
expressed how they were active in the beginning of the project but realized that
their involvement had low influence on identifying solvable problems and on the
development of the system. As with previous experiences, once again no one
seemed to listen to them. At this point, experiences from the past seemed to trigger
anger and disappointment among participants, and the importance of being listened
to and having unanswered questions can be interpreted as participants felt low
power. The staff’s expressions about previous and present feelings of not being
listened to are interpreted as experiencing “low confirmation”. They stated that few
people outside of their workplace understood what their work was actually about
and what conditions they had to manage. They expressed a lack of being confirmed
overall, not just from the organizational management. There were also expressions
that arguments regarding the beneficial aspects of using ICT systems did not portray
the reality of their situation – i.e., care workers’ everyday experience. The staff
pointed out that there seemed to exist a need to look outside the organization to
43
solve problems or for expertise in development work, seldom taking into
consideration all the potential existing within the organization. When some of the
staff spoke of these issues, they seemed resigned.
“Reciprocal understanding” pictures how FLM and staff, although with some
expectations on each other, understand each other’s position. The staff were well
aware that FLM had very little power and they described them with words like
“marionettes”. The FLMs’ position was recognized to be difficult, as they lacked
knowledge and information at times about the on-going project and did not act as a
leader in relation to the project. Staff lacked motivation in using the ICT systems
and FLMs lacked information and a mandate to make decisions for the project.
FLMs described that similar projects had been poorly handled and lack of
information was common. Furthermore, they recognized an awareness that staff
somehow felt that the systems were meant to control poor work performance and
thought that staff could feel offended by these kinds of projects.
44
Paper IV: Technologies in elderly care – Values in relation to a caring
rationality
In study IV, four values were identified: “Presence”, “appreciation,”
“competence”, and “trust” (Table 8).” Values were interpreted in relation to what
staff believed was good care and when staff accepted or did not accept technologies.
The staff’s arguments were sorted to each value.
Table 8. Arguments and interpreted values
Arguments about wanting to focus on the person behind the illness and making
them content and satisfied have been interpreted as relating to the value of
“presence”. “Presence” is a value that raises internal conflicts between taking care of
the elderly person by being present on the one hand, and the need to effectively
attend to technologies. To gain acceptance from caregivers, the technology had to
facilitate the possibility for the staff to be mentally focused on the care receiver and
ensure that staff could still remain attentive to the care receiver. Using one’s hands
Arguments Interpreted value
Focusing on the person behind the illness
Making the care receiver content and satisfied
Interacting with the care receiver without disturbance
Time-releasing technology
Presence
Getting approval and appreciation from next of kin
Being listened to
Being seen as someone who can contribute
Appreciation
Knowing what and how to document
Being emphatic and skilled in non-verbal language
Having knowledge in diseases and managing symptoms
Competence
Working without feeling stressed
Being able to trust their employer
Working in a calm environment
Evaluating critically
Trust
45
(e.g., the physical dimension of the work) was interpreted as essential as these
working tasks were tasks where positive feedback could be an outcome.
Technologies that allowed the caregiver to remain present and focused on the care
receiver were ascribed a positive value, since they allowed the caregivers to interact
with the care receiver without being disturbed.
When caregivers reasoned about the work in relation to technologies, they accepted
the technologies that gave more time for the interaction and made it easier to be
attentive to the care receiver during some physically heavy routine work. It also
became clear that “presence” was important because it was in the interaction they
felt confirmation and meaning in their work. When they could see that the care
receiver was content and satisfied, they felt happy because they knew they had done
something good.
Participants also valued being shown “appreciation” by others than the care receiver
and they wanted to be seen as someone who could contribute to the organization.
When they were not listened to, they felt they were not even given the possibility
to contribute. Participating caregivers gave value to conversations with next-of-kin,
since out of these they could interpret signs of satisfaction or disapproval.
Sometimes caregivers felt the next-of-kin did not trust them; and these incidents
were somehow taken as a critique as to whether they were doing a good or bad job
and therefore this kind of feedback was important. Being appreciated by next- of-
kin was a part of their everyday work and equally important as being attentive to
the care receivers.
Caregivers recognized the value of having “competence” in a variety of areas and
that knowledge was not constant but in need of being updated. Perhaps most of all,
it was recognized as important to be capable of understanding nonverbal language
and interpreting people with severe dementia and people with psychiatric disorders.
Furthermore, they valued having skills in recognizing different symptoms of both
chronic and acute illness and how to manage these symptoms. The employer’s
46
emphasis of the importance of documenting in an accurate way made caregivers
question their own capabilities. Caregivers were well aware of the importance of
maintaining social record documentation as this was an important source of getting
relevant information and they wanted to know what and how to document.
The last value was “trust”. When caregivers described the importance of working in
an organization where they trusted their employer, they expressed an internal
feeling and they sometimes became emotional. Caregivers most often used
sentences like “working in a calm and trustful environment” to describe what
conditions were desirable and what they wanted to feel at work. Participating
caregivers wished that they could trust their employer to take responsibility and
critically evaluate any changes before even thinking about implementing them to
spare staff useless disturbance. To work in a calm environment was described as a
prerequisite for staying focused in their work. One plausible interpretation of the
caregivers’ reasoning about mistrust was that they already worked under strained
conditions, and many of their emotions during the interviews were a result of
already dealing with more than enough stress.
47
DISCUSSION
The overall aim of this doctoral thesis was to describe and interpret health and social
care staff’s expectations (Paper I), perceptions (Paper II), experiences (Paper III),
and values (Paper IV) when changing work routines by introducing ICT. In many
of the discussions described in Papers I, II, and III, participants, by arguing for or
against the ICT solutions discussed and developed during the project, seemed to be
trying to find the meaning of the project. When they asked questions about the
object of the FIA-project and the benefits of ICT applications and when they
argued in support of any possible extrinsic values related to the ICT, they seemed to
be searching for meaning.
During the interviews numerous emotional expressions came forward when the
participants related present changes to previous experiences. They talked about
frustration and anger related to being excluded and not being listened to (Paper I, II
and III) and exhibited resignation about not being confirmed and having little
power to influence their job (Paper III). They also talked about not trusting their
employer and questioned why the employer did not evaluate if the changes or
R&D projects were even needed (Paper IV).
The life-world perspective
Results can be interpreted in different ways. When reviewing literature I have
addressed the concept of the life-world and rationalities, in Alvesson and Sköldberg
(2008), Andersen (2003), and Habermas (1981). These texts helped me understand
the results of this thesis. I did not have a life-world perspective when this research
was planned and performed, but I found that the results could be interpreted from
the perspective of the participants’ life-world, especially Habermas’ (1981)
development of the idea. That is, the participants’ life-world (their inherent and
extrinsic values) determined how they made sense of the change or, in this case,
why they did not understand the purpose of the change. Habermas, at least in The
48
Theory of Communicative Action (1981), says something to the effect: What I believe
is who I am and who I am is what I believe (i.e., why I believe x is because that is
who I am, my life-world) to speak of the qualities of my life-world is to devalue
them. That is, the life-world is independent of a system (bureaucratic or political)
but when it is “colonized” by a system (such as the ICT), practical rationality
(genuine, authentic, individual rationality expressed in ideal communicative
acts/situations) is colonized by instrumental rationality, forces beholden to markets,
profits, systems, etc., sacrificing the individual’s sense of self and self-determination,
forces that remove the sense making and meaning construction possibilities from the
individual.
According to Habermas (1981), life-world is a horizon of different subjects that in
an inter-subjective process share and understand the same life-world. The life-world
is taken for granted and is an on-going process of actors in a cultural context, in an
inter-subjectivity of mutual understanding of symbols and language. In this thesis,
the cultural context of caregivers means that the meeting between speaker and
hearer, among colleagues (caregivers) and sometimes care-receivers, is the life-world
in which they raise reciprocal claims on good care. Communicative actors always
move within their life-world and they cannot step outside of it (Habermas, 1981).
Being attentive and present in a practice colonized by ICT systems
Participants described the importance of being present (Paper II and IV), of taking
responsibility for the care-receivers’ shifting needs (Paper I), and, not surprisingly,
their descriptions clearly bring to mind a caring rationality. The participants were
focused on understanding both verbal and nonverbal communication (Paper IV),
which was seen as important aspects of being present. The interpretation of how the
participants perceived their work is based on Tronto’s (1993) four elements of a
feminist ethics of care; attentiveness, responsibility, competence, and reciprocity.
Habermas (1981) believes meaning is created in everyone’s daily practices in
intersubjective processes, where communication between persons in a specific
49
culture plays a central part. The way people find meaning is connected to their way
of perceiving the world, communicating it, and making it comprehensible and
logical. These perspectives are constructed by rationalities. ICT systems that
disconnect people from their life-worlds might result in loss of meaning. ICT
systems work relatively independent of consent between people and do not respond
to specific situations or communicative acts and ignore social norms. The system
cannot communicate and be attentive to immediate care needs, and in the end the
system’s intrusion will create crisis in the life-world of caregivers, a gap between the
life-world of the caregiver and the rationality ICT systems, ultimately undermining
the legitimacy of an individual’s life-world. This is what Habermas (1981) calls “the
system’s colonization of the life-world”. Crisis in the life-world might be
experienced as meaninglessness, loss of trust and legitimizing of the political
institutions, loss of solidarity and uncertainty in the personal identity (Andersen,
2003).
Caring rationality (in Habermas’ terms, practical rationality) and technical rationality
are based on fundamentally different values, often resulting in conflicts. There are
occasions, such as the one presented in this thesis, in which different ICT systems
based on a technical rationality colonize the life-world (cf. Habermas, 1981) of
caregivers and what generates meaning for them. Managers, project leaders, policy-
makers, and companies impose their understanding or meaning (i.e., the
technical/instrumental rationality perspective of the systems they are embedded in),
and this meaning may not coincide with the caregivers’ life-world perspectives.
That is, the technical/instrumental rationality expressed by these bureaucrats can
ignore the caregivers’ life-world perspectives, often manifesting in tension,
resignation, and outright conflict.
Participants (Papers I, II, and IV) highly valued being present when meeting the
care receiver. Since meeting the care receiver was the main source of feeling
confirmed, a possible interpretation is that the degree to which any technologies are
50
accepted is based on the conception of whether it supports the interaction between
caregiver and care receiver. The results of this thesis agree with other studies
(Blomberg, James & Kihlgren, 2013; Edvardsson, Fetherstonhaugh & Nay, 2010;
Gustavsson, Asp & Fagerberg, 2009; Häggström & Kihlgren, 2007; Reese et al,
2009), where the results showed that staff in elderly care talked about the
importance of building relationships and that appreciation from care receivers gave
them energy to cope with their work.
In the context of this thesis, technologies (or ICT) are instrumental. They ought to
be considered as a means to an end that relate to the intrinsic value of good care.
ICT, or any technologies, can and will be given extrinsic value if and when they
support the intrinsic value of good care. The values in Paper II and Paper IV are all
aspects in the care context that needed to be supported by the DSM. The DSM, on
the other hand, can only be described as instrumental, as it relates to the values
identified in Paper II and IV. The staff’s argumentation considered the extent to
which the DSM connected or disconnected staff from their life-world, based on
supporting or not supporting values of importance in their immediate cultural
context.
These results reveal that in the realm of a caring rationality, in the context of staff’s
professional life, a caregiver’s motivation and meaning was linked to the practical,
sometimes physically as well psychologically intimate, care work they provided.
Values emerged from that specific context where caregivers and care-receivers
meet. Such links provide clues to motivation to care in the context of professional
care and nursing work (Moody & Pesut, 2006). Dealing with changes and the
amount of energy that process takes required staff to shift their focus from the care-
receiver to the use of the technology in ways they considered unnecessary. The
result gives a picture of the caregiving process and its challenges from the
perspective of the caregivers. This perspective needs to be taken into consideration
51
and the concept of caring rationality needs to be put on the political and
organizational agenda.
Care staff, FLMs, and RNs work in organizations that constantly change in
revolutionary and evolutionary ways (Alvesson & Sveningsson, 2008). There is a
risk that care staff, FLMs, and RNs will lose their sense of purpose in their work,
will have less work satisfaction, and more often will find themselves struggling for
meaning. Increased demands to become efficient (e.g., via ICT) might disconnect
staff from what creates meaning in their work. Struggling for meaning to
extensively and often, are demands that care staff, FLMs, and RNs not should have
to deal with. If they are forced to do so, it will probably have a negative effect on
their sense making and meaning at work in the long run.
Management of the change project
Participants asked questions about the purpose of the FIA-project, about benefits,
and did not recognize the outsiders’ view of the project as beneficial. They also
wanted to know how it would be possible that ICT would increase the status of
their work and they distanced themselves from the changes taking place (Papers I,
II, and III). Although they wanted clear and transparent management of the change
process, they found the process to be unclear (Paper III) and not as useful for them
as for others (Paper I). This view might contribute to the fact that care staff
perceived the ICT solution as not needed and not practical (Paper II). They also
wondered where and who had decided about the project; that is, they questioned
management’s decisions and information (Papers I and III). In line with the results
of this thesis, Fläckman, Hansebo and Kihlgren (2009) found that staff in elderly
care experienced decreased possibilities to influence organizational changes.
Adapting to a new situation made staff struggle, since under these conditions they
seemed to lose something important, their pride and work satisfaction (Fläckman et
al, 2009).
52
Participating staff struggled not only with trying to find how the ICT solution
could be given an extrinsic value to support good care but also with the project and
its purpose (Papers I, II, and III). Based on participants’ arguments, it might be
possible to understand their reasoning about the meaning of the project.
Furthermore, a good economy (Paper II) was identified as an extrinsic value, a
prerequisite for the municipality organization to provide good care.
Policy-makers and managers tend to believe that solutions to external and internal
demands on efficiency and quality are to be found in different systems, in this case
ICT systems (Tillväxtverket, 2010). They are searching for solutions constructed on
instrumental/technical rationalities. By adding more systems to navigate, systems
that “colonizes the life-world“ (Habermas, 1981), the care staff’s and RNs’
everyday work might become even more demanding.
Care work is based on a caring rationality, a rationality that should be supported by
management. When participants expressed their view on management (paper I, II,
II and IV) it was clear that the message of importance received from managers, was
managers’ focus on good economy (instrumental rationality). One example of this
is staff’s questioning of who would economically benefit by the introduction of
these electronic systems, as they could not figure out if and how the municipality
would gain economically by using the ICT (Paper II). A plausible interpretation is
that the caregivers’ life-world perspectives collide with management’s, technicians’,
and policy-makers’ life-world perspectives (or the instrumental/technical rationality
of these systems embodied in these actors), as they might have a different way of
perceiving the world. In addition, different life-world perspectives most certainly
make people find solutions to problems that fit their respective life-world
perspective. The technical rationality, as part of an objectifying way of perceiving
the world (Habermas, 1981), looks to systematize and organize solutions that work
independently of people’s immediate life-world, while the care rationality requires
53
flexibility and getting to know the person and being present in response to shifting
needs (Edvardsson et al, 2010; Gustavsson et al, 2009; Tronto, 1993).
Focusing on ICT and improving work procedures, the FIA project was not seen as
having high importance to the participating staff (Papers I, II, and III). The project
was founded on and legitimized by overall goals of policy-makers about using ICT
systems to improve efficiency and quality in care (DS 2002:3; E-health strategy,
2010). Based on the results of this thesis, an interpretation could be that there was a
mismatch between the goals of the project and how participants perceived the
project. This mismatch is evident in the narratives of participants searching for
sense-making. Policy-makers might actually represent predominant voices for ICT
systems as solution for demands in healthcare. This can be interpreted as suppression
of caregivers’ voices being heard, on a societal level, and on how to achieve a
common goal of good care.
The emphasis towards increased use of ICT has become a predominant voice in
society, legitimized by policy-makers and management in healthcare organizations.
In the interviews with participating staff the interpreted values were founded in a
caring rationality. When rationalities and values belonging to a
technological/instrumental way of understanding the world become the
predominant voices in society, care and its challenges from care workers’
perspectives are placed in a peripheral location. This exile and silences care workers’
voices, concerns, perspectives, and professional knowledge (Tronto, 1993). This
thesis represents an attempt make visible arguments presented by staff in relation to
care and technologies, and specifically arguments related to DSM. According to
Andersen’s interpretation of Habermas’ ideal speech situation (Andersen, 2003), the
good argument has its own value in a society and in the good society everyone’s
argument is given space and time to be expressed. A free dialogue is the basis for an
ideal speech situation, a communicative act not influenced by overt or hidden
skewed power relations. Power institutions, of which policy-makers are a part, can
54
be a means for effectively reaching common values (in this thesis good care), but in
some cases power institutions can be oppressive. Power institutions can sometimes
encourage particular interests in society or some group’s particular interests. The
emancipatory research intent is to question possible skewed power relations.
Needs of confirmation and appreciation
In the group interviews and in the individual interviews, the participants were
somewhat emotional because they felt they were being ignored (Paper II), they
were not being confirmed (Papers III and IV), and they did not have the power to
influence the process (Paper III). The participants did not trust the employer and
questioned why the employer did not assess their needs before starting any change
processes or projects (Paper IV). Furthermore, it seemed as if emotions were
triggered when staff expressed that nobody listened to their opinions and this
seemed to be a common experience of change processes taken place in the past.
Nussbaums’ (2001) theory “the intelligence of emotions” gives a plausible
interpretation of emotions expressed by the participants. For Nussbaum, the rational
and emotional are intertwined and interdependent in a learning process. Without
emotional intelligence, people cannot orient in the world. Emotions are
intertwined with our understanding and a source for our consciousness (Nassbaum,
2001). Emotions cannot be separated from what we think about something, from
how we perceive the world. If they were, it would mean that we separate emotions
from our identity. Emotions, thoughts, judgments, and actions are connected to
each other.
However, participants also expressed positive emotions as part of their work and
how these emotions related to moments and situations when good care was given
in reciprocal responsive process (cf. Tronto, 1993) with the care-receiver (Papers I,
II, and IV). Emotions are of importance since they can make the mind more alert,
but also the other way around when not balanced with reflection. The combination
of thought and emotion makes the capability of empathy possible (Nussbaum,
55
2001). For that matter, it can be said that emotions are essential to the participants
described in this thesis, as their emotional lives are a prerequisite for being attentive
and receptive to care receivers, for their ability to interpret how care receivers feel.
A reflection on research and society needs to be done, since I do agree with
Alvesson (2006) that research is a political activity; the difference is to what extent
researchers make this explicit to themselves and their audience, if at all (Alvesson,
2006;). In this thesis, the research is actually a small part of an overall strategy
coming from policy-makers’ goals and decisions to give economic support to
projects aimed at developing the region by increasing the use of ICT. Policy-
makers’ emphasis on ICT, in my view, is an implicit message that ICT in itself is
something positive. This needs further investigation with an emancipatory intent.
METHODOLOGICAL CONSIDERATIONS
The participants of this thesis were, except four FLMs in Paper III, selected within
the R&D project of FIA. This might have affected the results of the four papers in
different ways. The FIA project had a time limit of three years and it was
predetermined that the work to develop and test the innovation had to be done
within three years. Of course, these circumstances might have had an impact on the
participants’ expressions, and these project frames were most certainly restricting
what was possible to achieve within the project.
The participants were required to take part in workshops, and later on to test the
ICT solutions. Even if I did emphasize the free choice of participation in the
research and data collection, they might have felt that this also was part of the
whole project and therefore compulsory. However, the fact that most participants
did talk a lot during the interviews, sharing many of their experiences and critical
points of views, makes me think that their attendance was voluntary and their
comments genuine.
56
Democratic validity is a concept that refers to the extent to which research is done
in collaboration with all parties who have a stake in the problem under investigation
(Herr & Andersen, 2015). It also deals with the extent multiple perspectives are
taken into account and the purposefulness in the research and change process. For
example, if some group’s interests are given more attention and solutions provide
uneven benefits, democratic validity is compromised. Democratic validity I would
say was not achieved in this project, because participants were unable to identify
any benefit or purpose associated with the project.
In the studies described in Papers I and II, in addition to myself, a second person
was present during the group interviews, taking notes and asking some clarifying
questions that may have been missed (Redmond, & Curtis, 2009). This person is,
like myself, educated in nursing and has a doctoral degree in that same subject.
Since the aim of this thesis was to study how health and social care staff experienced
the change project and ICT, it can be stated that the research question is
multidisciplinary. Perspectives from work science could have improved Papers I and
II and it could have been advisable that the second person would have been
someone with a background in different research field (e.g., organization, gender,
management, or human work science). This diversity in disciplines could have
broadened the perspective and given rise to different kinds of theoretically
grounded questions.
In Paper II, I used the concept of “group interviews” to describe the technique for
data collection; while in Paper II the concept “focus group interviews” (McLafferty,
2004) was used. With some time perspective and reflection, it can be emphasized
that the techniques used (whether it was the technique used in Paper I or Paper II)
were similar, and with the intent was to create vivid discussions with as many
different opinions as possible. These techniques were used to create discussions
between participants and, therefore encouraging group discussions, is the kind of
interactions I was looking for and that actually took place. This means I do agree
57
with Dahlin, Ivanhoff & Hultberg (2006) that the concept of group discussion is
more suitable as a linguistic expression.
Workplaces are embedded in a culture built on collective norms (Habermas, 1981).
Individuals are social, and in interactions with each other they create cultural norms
at a workplace. Admitting this also means admitting that there is a risk that some
individual opinions never come forward during interviewing groups. However, the
authors of Papers I and II were aware of this and explicitly talked about openness
and respecting different opinions before starting the group discussions each group
and participants were reminded of this during the interviews. It was stated that
discussions should remain between the participants and not be talked about
afterwards. Whether everyone kept to this agreement, of course, is impossible to
know. However, there were groups that had opposite opinions and arguments, and
there were groups where participants sometimes questioned each other and this
strengthens our picture of the discussions as open and dynamic.
A limitation in Paper III was the number of FLMs. It would be fruitful to further
investigate to what extent FLMs have influence on or are involved in decision
making when it comes to changing work procedures for staff at the wards (ENs and
NAs). More effort could have been made to recruit other municipalities to obtain a
broader perspective of the FLMs. The authors of Paper III decided to not enlarge
the data collection to cover further municipalities, since it was difficult to find
municipalities going through similar changes at that specific time. The fact that
women are in absolute majority in municipal elderly care means that very few men
have been interviewed. However, this is perhaps not a limitation, but a
representation of the fact that the healthcare sector is dominated by women in
Sweden as well as in the rest of the world. The limitation of the thesis is perhaps
more related to the fact that a gender perspective was not applied in the analysis of
the data. This could have contributed to highlight possible power imbalances
related to gender.
58
In this thesis, credibility was achieved by asking all staff involved in the project to
participate in the data collections in an attempt to reach variations of experiences
and to shed light on the research question from several perspectives. Furthermore,
in the analysis I always started by reading the whole text before deciding if I would
use the whole text or extracting parts of the text for the analysis. Furthermore,
when I decided to pick out part of a text, going back to the original text was part of
the analysis. Credibility also deals with how well categories or themes cover data
(Graneheim & Lundman, 2004) and the process of defining these categories and
themes included all authors of each paper, a process that included reading and
becoming familiar with the texts and being part of group discussion.
Transferability is another aspect of trustworthiness (Graneheim & Lundman, 2004)
and is another quality aspect of qualitative research. Transferability is critically
viewing whether results can be transferred to other settings and groups and for the
results in this thesis the limitation may be that the context of the work is very
specific in regard to the R&D project and its specific goals, so the results need to be
understood in relation to this context. Simultaneously, there were other changes
on-going and the experiences among the staff were that not all previous projects
were implemented.
Participants in all four papers sometimes expressed a general disappointment in
management. In addition to complaints about the actual R&D project, the
participants shared experiences related to previous changes triggered by the on-
going changes. The participants’ experienced several on-going changes and previous
changes, so the results of this study can be related to more than just the change
process of developing and implementing ICT. The results in this thesis may
contribute to the awareness that more consideration needs to be given to situations
where people are confronted with several changes. Staff struggle with sense-making
and finding meaning, especially when external projects are established as change
59
process models. The results of this thesis might contribute to some understanding
and could be transferred to other contexts (such as education).
When people talk about something they are experiencing in the present (in this
thesis a change project), they also explicitly or implicitly are reflecting on earlier
similar experiences. Stories are not separated from our pervious personal
experiences, and they are not separated from the social and work context we find
ourselves in. Furthermore, I agree with Thorne, Kirkham & MacDonald-Emes
(1997) that attempting to eliminate all biases in qualitative research is naïve, so the
researcher should explicitly account for the influence of bias as much as possible.
For example, in Papers I-IV we identified and discussed our pre-understandings,
interpretations, categories, and themes in small groups and in seminars. Although
the interpretation in Paper IV was a conscious process, interpretations are also an
unconscious and intuitive process (Alvesson & Sköldberg, 2008; Charmaz, 2006).
Any interpretation depends on and is limited by each researcher’s previous
understanding and theoretical knowledge. To gain trustworthiness in the final four
values interpreted in Paper IV, I have reread the transcribed text bearing in mind
these three questions: 1.) What do these people consider important when they are
talking about care and ICT? 2.) Are the four interpreted values valid? and 3.) “Can
I see them in their narratives, in the transcribed interviews? Thus, the intention of
this thesis was not to find any objective truth, as there are multiple constructions of
how we interpret and view phenomena and the world around us (Merriam, 2009).
60
CONCLUSIONS AND IMPLICATIONS
Staff in today’s health and social care organizations often find themselves dealing
with complex and demanding situations characterized by frequent on-going
changes. People in the organization are trying to understand what is happening and
why. Based on the results of this thesis, it is important to highlight that participating
staff were trying to understand why the changes were needed, and much of their
energy was linked to attempts of sense making with respect to the developed ICT
solution. When staff was unable to understand the purpose of a change, they were
negatively affected. To minimise this negative response, the actors purposing a
change could appeal to the values of the healthcare staff, relating the purposed
change to the staff’s life-world perspectives.
Change processes associated with ICT in healthcare and social care often focus on
finance and effectiveness, whereas sense making and finding meaning related to the
caring rationality seemed to be ignored or simply left to the staff. Disturbance-free
interactions with the care receiver were prerequisites for accepting any technologies
and staff wished to take responsibility in care work in an organization with clear
visions and management. Furthermore, what good care is and who is defining it
deserves further investigation, especially when there are different stakeholders
involved. R&D projects and researchers should consider that from the staff’s
perspective it would be beneficial to use approaches where power relations are
questioned. Managers in healthcare and social care organizations should also
encourage staff to present their own ideas, encouraging them to be initiators of
change. Furthermore, a deeper understanding of the management perspective
during changes involving ICT could be further explored. On the European,
national, and local level, policy-makers initiate changes that managers in healthcare
and social care organizations are required to implement. Often, the purpose of the
change is lost as the mandates make their way from the top decision makers, to
middle management, and finally to the staff responsible for implementing the
61
change, resulting in unclear and irrelevant changes from the perspective of the
caregivers.
Overall, for decades, the healthcare sector has been subject to and driven by values
focusing on efficiency and economic savings rather than based on caring
perspectives formulated by staff and/or care-receivers. As a society, it seems
desirable to improve and develop caring practices, so we should also begin by
questioning driving forces and underpinning values: From where and by whom are
changes defined? The values interpreted in this thesis’ results could be used to make
evaluations of ICT before any implementation. In doing so, the intended
technologies will be evaluated according to whether they support the values of
importance for good care and thereby make sense and bring meaning to the people
who are actually responsible for delivering care.
ICT has become a worldwide used tool in various contexts, and healthcare and
social care organizations are no exceptions. In general, policy-makers see ICT as a
solution to many of the challenges faced by healthcare and social care organisations.
In the future, ICT healthcare and elderly care will be the market for health-
promoting, care-oriented activities, services and products will grow and will be
designed to meet customer needs and wishes (E-health strategy, 2001). The
management of healthcare and social care organizations (in their desire but also
demands, to transform organizations into efficient, modern, and customer-focused
organizations) is approaching the phenomenon of ICT in healthcare. Therefore, it is
easy to understand why managers might think they are doing the right thing when
trying to develop quality processes using new ICT systems.
Future research could focus on how ICT systems, which controls and systematize
working tasks, affects staff. It would also be of interest to investigate how changes in
healthcare and social care are achieved. so that trust is built and not shattered.
62
A FINALE REFLECTION
In this thesis, the concept of empowerment could have been used, in an action
research approach, for staff and managers. Empowerment can create an organization
where critical awareness and reflection over daily practice becomes a routine. This
could contribute to building a healthcare organization that encourages diversity and
initiative taken by staff, using the power of people and the knowledge that already
exists within the organization.
Using a gender perspective could have shed light on gender power relations in care
and ICT, two highly gender-segregated sectors. The belief that technologies will
increase the status of and attract young people to elderly care is counterproductive
to the development of care work. Care as a practice is a difficult body and relational
work; it is dirty and demanding and it needs to be recognized as such. Twigg
(2004) states that the body and the work connected to the body are often seen in a
negative light, since it often is associated with human waists, feces, pee, vomit,
sputum. Therefore, it needs to be recognized that care work actually involves
managing hazardous fluids and one’s own disgust. The bodily and intimate aspects
of the work might also contribute to the fact that these intimacy and bodily aspects
of the work should, or are not needed, to further explore. These questions have
persistently, throughout the history been left aside in research. Equally much these
aspects of care have been left, and still remain, in the peripheral location of everyday
life for many women (Hirdman, 2001) and it seems as if these every day practices
of care work will remaint in the private sphere(Tronto, 1993).The focus on
technical and instrumental rationalities are in thus still predominate in today’s
society. Technologies, on the other hand, can sometimes create a distance between
the body and the involved staff. It is well known that specialties in the healthcare
sector that are high-tech are given a higher status both within the nursing and
medical professions (Liaschenko & Peter, 2002). Twigg (2004) as well as Liaschenko
and Peter (2004) believe that research should deal with the body and bodywork in
63
general, as these aspects of the work as a fact are central to community-based care.
It is damaging to neglect the fact that care of persons within municipality healthcare
and social care mainly deals with relations with care-receivers’ multiple intimate
needs and deteriorating bodies. These aspects of care work, related to technologies
as well as gender aspects of the work, need further exploration.
The DSM was a tool for assisting a work procedure, administering medications, and
(according to the participants) improving statistics so as to “show off” quality
improvements (Paper II). Figures and numbers have become part of what we do
every day. Much of our time is spent on measuring – hours of work, body fat,
income, weight, calories, expected length of life, costs, savings, etc. In a world that
so highly values measuring, I do wonder what will happen with values that are not
measurable. What will happen with values such as trust, empathy, wisdom,
presence, and care?
64
TO BE PREVILEGED
Throughout my life, in conversations with my mum about love, family, life, death, joy and
sorrow, she used to tell me; “Maria, one must never give up.” I never gave any response to
you mum…
These years of doctoral studies have been educational in numerous ways. I have
been given the possibility to read, reflect, investigate, question, and most of all, to
meet people that has given me so much. It has been intense years of getting to
know more about research, about healthcare organizations, about people and about
myself. It has been an inner and outer journey. It is not possible for me to describe
everything that this education has given.
There are many persons that I warmly remember as inspiring and believing in me
and my capabilities. You are all kept in my heart and memory.
To be privileged is something that I most of all recognize to be. There are many
things I never have chosen, but these circumstances are prerequisites for doing
everything that I have done during these five years. I’m deeply grateful that:
I was born in a part of the world were education is accessible for many, almost
everyone.
I am part of a society that still has equality relatively high on the political agenda, a
society that collectively takes responsibility and makes it possible for people to
educate themselves regardless of their background. I am deeply thankful for the
supportive systems that I found myself surrounded by.
I am deeply thankful and I bow to all strong, beautiful, supportive, warm, truth
telling women I have met. I have met many throughout my life and I still do…
65
I am healthy and I have been given the cognitive capabilities to read and write, to
think and reflect. I still have a body that supports me, in my walking, sitting and
using my fingers. My body and my mind still sustains me in different ways, to sit
many hours and to sometimes escape in a daydream... None of this I take for
granted.
I also feel gratitude to all mistakes I have done, and to things gone wrong. These
experiences, at times sad and quite tough, slowly break down all my prestige and all
my defenses. Hopefully this will make me a genuine and humble person someday.
To be privileged also implies responsibility. Did I make the best out of that
privileged position I recognize to have? Have I been responsible enough? To be
privileged gives me a sense of never being or doing enough, there is always
something more or better that could have been done. Being privileged and
recognizing it to the fullest gives me a bad consciousness, and a sense of not having
done enough. That is something I have to deal with.
…I have been thinking about what you said mum, and, I can give you an answer today.
I agree, giving up has never been and will never be an alternative. And I am privileged,
because most of the times I can still choose whether to give up or not.
66
TACK
Det finns personer som betytt särskilt mycket för mig under min forskarutbildning.
Tack…
Angelica, för din totala förståelse som alltid är en del av dig. Alla diskussioner om
perspektiv och om metoder, forskning och om livet, om kärlek och passion. Alla
sms! Alla gånger vi inte tyckt likadant. Och för din energi.
Anita, i början av min forskarutbildning sa du; ”kom ihåg att även njuta av
forskarutbildningen för det är en fantastisk resa”. Jag lyssnade på det du sa.
Annette, för din beslutsamhet. Den inspirerar mig. För alla år innan LTU. För att
du varit och är min vän. För gott strävsamt arbete på kandidat och magisternivå.
Det var vi två då. Du var strukturen och formalian.
Annika, min livsmentor, din tro till att jag skulle ro detta i land. Din livskunskap
och din intuition. Du är bara ljus vacker kärlek.
Christina, för det sätt du tog dig an mig när jag kom till institutionen. Alla goda
skratt vi haft. Alla samtal om våra barn och den dagliga tillvaron. Din lugna varma
vishet fattas mig ibland.
Daina, för dina perspektiv om rättvisa, arbetsvillkor och fackliga frågor. För din
förståelse då jag inte kunnat vara närvarande på styrelsemöten. Du är en klok
person.
Inger, det avslappnade sätt som du sagt åt mig att välja mina strider. Din varma
tydlighet. Du har varit lätt att vara med. Tack för att du stått ut med mig och stått
kvar. ”Killing my darlings” har inte alltid varit lätt, och vissa blev nog kvar
Lisbeth, för de få (alltför få), men ack så fina pratstunder vi fått.
67
Kajsa, min älskade alltid hårt arbetande, lillasyster. Tack för alla diskussioner, all din
nyfikenhet och vilja att ta del av det jag gjort under dessa år. Du inspirerar mig. Jag
hoppas att även jag kan inspirera dig. Du är bäst!
Karin, för allt du lär mig genom att vara som du är. Du är struktur, stabilititet,
vishet och kunskap, blandat med värme och mycket engagemang. Fast jag varit arg
på dig ibland, har du betytt mer för mig än jag finner ord att förklara. Det kommer
alltid vara så.
Katarina, för ugglorna. För att du alltid fått mig känna att jag är bra!
Kicki, storasyster som jag alltid sett upp till. Tack för att du såg tjänsten som
doktorand. Du tyckte det var något som borde passa mig. Det var tack vara dig jag
faktiskt sökte.
Maria, för att du läst och intresserat dig för det jag gjort. För visioner. För
bekräftelse. Tack! Vi ses!
Maud, för dina pep-talk i korridoren. Särskilt sista tiden. ”Äh, kom igen nu”
Mia (PT Mia), för att du hjälpt mig att än mer inse värdet av kroppen som en del av
helheten, och hur en stark kropp bidrar till en helhet av balans. Mellan psyke, själ
och kropp. I allt sittande…
Sigrid, min mamma. För alla samtal om livet och alla varför…
Sofi, för dina insikter och stöd i svåra stunder. Din värme. Ditt leende utanför min
dörr i korridoren då du avbrutit för en kaffepaus. Din vänskap. Alla fina samtal. Det
har bara funnits värme de samtalen. Förståelse.
Tiina, min chef, för ledigheter med kort varsel.
Ylva, för din rättframhet och kvicka kommentarer. Din kunskap och dina
perspektiv är ”annorlunda”. Din förståelse när saker och ting trasslat till sig. Jag är
68
oerhört glad att du blev delaktig i min forskarutbildning och stannade kvar. Det har
betytt oerhört mycket för mig att ha dig med.
Sist och absolut viktigast. Denise, Kristoffer och Viktor. Periodvis har jag haft
mycket att göra, datorn har ockuperat köksbord, artiklar har legat huller om buller.
Jag har varit i min ”bubbla” av och till, och tillvaron har varit tämligen bohemisk.
Jag har kanske inte varit och kommer aldrig bli en mamma enligt normen. Det har
inte alltid varit lätt. Att som kvinna ägna mycket tid till sitt arbete är än idag inte
fullt accepterat. Kraven är många, man ska vara tillgänglig, engagerad och delaktig
på många olika sätt, i skolan, i fritidsliv osv. Jag har inte alltid räckt till. Jag är
medveten om det. Men jag älskar er mer än allt, oavsett och för alltid. Det är ni som
är min drivkraft och yttersta motivation, att alltid sträva vidare…
69
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Paper I
Staff Expectations onImplementing New ElectronicApplications in a ChangingOrganization
Maria Andersson Marchesoni, RN; Inger Lindberg, PhD, RNM;Karin Axelsson, DrMedSc, RNT
This study was undertaken to describe staff expectations prior to implementation of new electronicapplications in a changing organization. Changes are a part of human existence; changes based onimplementation of technology and information and communication technology are taking place inthe health care sector globally. The Swedish public health care and social care sector is taking asimilar path. A qualitative approach with group interviews of 23 staff divided in 5 groups was per-formed. Latent content analysis was used to analyze the transcribed interviews. The theme, takingstandpoint today in relation to the past, emerged from 3 areas of discussion: ‘‘distance holding,’’‘‘ruled by the organization,’’ and ‘‘health care development in the future.’’ New restraints on staffaffect the caregiving process. Managers should consider whether a particular change is revolutionaryor evolutionary and act in the change process according to the possible psychological impact of thechange. Key words: change implementation, electronic applications, health care staff, organizational
change
HUMANS EXIST IN A WORLD of changes;
change can be regarded as one of the
few constants of history,1 and the health care
sector is no exception. Effects on changedownership from public to private2,3 have been
studied and also changes from centralized
ownership to empowering partnerships.4 In-
formation and communication technology (ICT)
has in general become a worldwide tool in
various contexts, and health care organizations
are included. In general, managers yearning for
rationalization and efficiency transform orga-nizations to modern customer-focused ones.5
Information and communication technologyis often used as a tool for achieving these
goals in the health care sector.6-8 Lee9 found
that implementation of information systems
led to feelings of dissatisfaction, in part related
to slow computer systems and changed inter-
personal relationships between staff members.
Information and communication technology
in health care settings has also been studied ina global perspective. Piotti and Macome10 dis-
cussed strategic issues for the implementa-
tion of ICT in Mozambique, suggesting a
global perspective. They also identified a risk
of ‘‘second hand’’ technology being dumped
into developing countries or a risk of imple-
menting inappropriate technology that is too
advanced and sophisticated. Chib et al11
found evidence for numerous benefits of using
mobile phones in an Indonesian context with,
for instance, better access to expert medical
advice. Obstacles were poor infrastructure and
also low technological literacy holding people
back from effective use. Noir and Walsham12
studied why ICT was enrolled in the Indian
The Health Care ManagerVolume 31, Number 3, pp. 208–220Copyright # 2012 Wolters Kluwer Health |Lippincott Williams & Wilkins
Author Affiliations: Division of Nursing, Department
of Health Science, Lulea University of Technology,
Sweden.
The authors have no conflicts of interest.
Correspondence: Maria Andersson Marchesoni, RN,
Division of Nursing, Department of Health Science,
Lulea University of Technology, 97187 Lulea, Sweden
DOI: 10.1097/HCM.0b013e3182619d73
208
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
health care sector, and their findings chal-
lenge the simplistic view that implementing
information systems will translate directly to
efficiency gains.
Staff perception of ICT in dementia care
showed that staff might have ambivalent feel-ings toward ICT and a fear of inhuman care.13
Findings have also revealed how trainees
relied on workaround as simplified routines
while staff demonstrating adaptive expertise
used workarounds as a part of a broader
network of people and communication tools.14
Individual and organizational perspectives of
staff perception toward ICT showed thathealth care staff are aware of and ready to
use ICT, although there is a lack of support on
the organizational level.15 In a Swedish context,
nurses’ experiences in neonatal care, using
videoconferencing for communication, illus-
trate how acceptance toward ICT depended
on personal technical skills, workplace cul-
ture, and benefits from the new technology.16
Savenstedt et al17 concluded the need of
an ethical discussion when introducing ICT
in elderly care, where aspects of well-being
and dignity are acknowledged and discussed.
District nurses’ (DNs’) overall attitudes to-
ward ICT were positive, and ICT was also seen
as a complement for communication but not
seen as something that could replace physicalencounters.18
Jansson19 studied how democratic values
came to surface when new ICT was imple-
mented. The process of implementation was
seen more from the technician’s perspective
than from the users. The context and social en-
vironment in which ICT is supposed to be
used were not taken into consideration.19,20
Technology in the health care sector is changing
the way tasks are performed. Caring tasks that
historically have been coded as feminine tasks
are not influenced by usage of the technology.
In this sector, women are still in great majority,
which means that stereotypes regarding codes
of gender remains.21
Developing new, sophisticated ICT solu-tions creates presuppositions for new prac-
tices in a diversity of professions such as care
in people’s home or working at distance.
Walivaara et al22 came to the conclusion that
the MDST (mobile distance spanning technol-
ogy) should be usedwith caution and that there
are central dimensions of value that MDST
cannot replace. Caution from a professional
perspective based on knowledge and ethical
considerations was expressed by participants.Describing staff in terms of gatekeepers does
not give a fair picture of the staff’s caution
regarding the use of MDST. A similar conclu-
sion was made from Huryk,23 where nurses’
attitudes revealed a fear that technology will
dehumanize patient care. Lindberg et al24 de-
scribed midwives’ experiences of loss and
grief over their former midwifery practice,but still they had visions of how to develop
their new professional role. Studies also em-
phasized the importance of skilled and sen-
sitive management in transitions, balancing
workload with the integration of the new
device.24,25
This background shows that ICT is imple-
mented in health care around the world. Staffhave a general positive view of the tech-
nology even if they also have some restric-
tions. In some studies, the staff’s attention to
patients set some restrictions on how and
when to use ICT. Some studies have focused
on democratic values or required manage-
ment skills during implementation processes.
The focus of this study is to obtain knowl-edge about staff expectations of ICT before
implementation, also considering ongoing
organizational changes.
THE STUDY
This study is part of a larger project aimed at
creating solutions for future health care usingvarious distance spanning solutions. The sec-
ond aim of the project is to create products
that support the commercial and business life
in the region. Staff from 2 organizations were
invited to participate in workshops. Work-
shops were conducted during autumn 2009,
intending to reveal areas where electronic
applications could improve future health care.Project leaders led the workshops, and the
authors of this study passively attended the
workshops. A diversity of areas was identified
during these sessions, and thereafter a process
Electronic Applications and a Changing Organization 209
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to find suitable technical solutions started to
support staff in the identified areas. Project
leaders having experience as a technician also
led this process.
Communication issues between staff in
social care in the municipality and staff inhealth care in county council were outstand-
ing areas in need of improvement. In August
2010, the first developed electronic applica-
tion was ready to be tested. Data collection in
this study was performed after the work-
shops but before implementation of the elec-
tronic application.
The aim of this study was to describe staffexpectations prior to implementation on
new electronic applications in a changing
organization.
METHODS
A qualitative approach was chosen to ob-
tain deeper understanding of staff expecta-
tions. To obtain a variation of expressions
and to open up for individuals’ unawareness
of their own perspectives, group interviews
were chosen as a method for data collection.Group interviews give the participants possi-
bilities of creating an environment where the
persons can express and react to each other’s
opinion and stimulate the discussion.26
Informants
Staff in one primary health care center (n =
40) organized under the county council and
employees in social care representing one
section of themunicipality (n = 25)were given
the opportunity to participate in the study.
A total of 23 persons agreed to participate.
Divided in 5 groups, the informants were in-
terviewed during April to August 2010. The
informants had between 5 and 40 years ofexperience in the actual occupation (median,
16 years). In 2 of the groups, there were
persons who had been involved in the work-
shops (Table 1).
Procedure and data collection
The leader of each group was informed ofthis study. Information to the staff about the
study was then provided at regular staff meet-
ings. After each meeting, written information
was left in each employee’s post-box. The
staff’s leader planned the group’s composi-
tion according to needs of the ongoing activ-
ities at the workplace. All group interviews
were conducted during the staff’s workinghours, and time limit was set to 90 minutes.
The interview techniquewas inspired by eth-
nographic methods according to Spradley.27
The foundation of this methodology is a tech-
nique similar to a friendly conversation, al-
though the aim of the conversation must be
clarified, and the interviewer uses an informal
approach.27,28 The interview guide was devel-oped by the authors of this study and was
aimed at supporting the discussions and was
not to be strictly followed. Questions such as
‘‘tell me what you know about the ongoing
project,’’ but also contrast questions such as
‘‘tell me what can be the benefit of this
Table 1. Participants in Group Interviews (n = 23)
Profession Group 1 Group 2 Group 3 Group 4 Group 5 Total Female/Male
Care assistants 5 5/0District nurses 4 2 6/0Enrolled nurses 2 2/0Occupational therapists 2 2/0Pedicurer 1 1/0Physiotherapist 1 0/1Physicians 2 0/2Registered nurse 1 1/0Welfare offices 1 1/0Physician secretary 2 2/0Total 5 5 4 4 5 20/3
210 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
application or what could be a hindrance,’’
were part of the interview guide.
The first author was the moderator during
the discussions in all groups. The modera-
tor’s task was to encourage informants to,
without restraint, express thought expecta-tions, fears, feelings, opinions, and experi-
ences. The second or third author was present
during all interviews. This person took notes
and assisted in asking clarifying questions. The
first author transcribed each interview verba-
tim. The length of the group interviews was
between 75 and 90 minutes.
Analysis
Latent qualitative content analysis inspired
byWoods andCatanzaro29 was used to analyze
the text. This process is concerned with the
meaning that can be identified in passages
of the text.29 The 5 interviews together wereconsidered as one unit to analyze. In some
parts of the text, there were many individual
expressions without any reactions from the
others, and in other parts, the informants
were sensitive to each other’s expressions
with their opinion, and they also completed
each other’s sentences. All interviews were
read for an overall understanding of the con-tent, and the text was sorted in the areas of
discussions. These areas are different from
the areas in the interview guide. The iden-
tified areas were then analyzed, and the text
was sorted in dimensions. Each area and di-
mension were then compared and discussed
between the authors. All 3 authors had full ac-
cess to the interviews andwere involved in the
whole process. During the process of analysis,
the text was condensed and summarized. A
diary of thoughts, questions, interpretations,
and everything that came to the first author’s
mind was done during the whole process.
These diary notes were also discussed be-tween the authors and were a base for in-
terpretations. This process was hermeneutic,
going from specific content and small parts
of the text to a wider sense of the whole, lead-
ing to a deeper understanding.30 The result of
this process was one overall theme.
Ethical considerations
The staff were informed about the study
in written form and verbally. They were in-
formed that participation in the study was
voluntary and that they could drop out at any
time without explanation. The Regional Ethi-cal Review Board in Umea, Sweden, approved
the project (Dnr 09-209M, 2009-1414-31).
FINDINGS
Analysis of staff discussions resulted in
areas of discussions (n = 3) and dimensions
(n = 11) (Table 2). The areas are presented as
headings, and the dimensions represent thevariations of expressions beneath each area.
An overall theme also emerged. In the findings,
quotes are used to provide an impression about
the communication in the interviews, although
no overlong example is used. All participants
in each groupwere given a number, between
1-5. All interviewed groups are represented
in each area.
Table 2. Staff Expectations Prior to Implementation of New Electronic Applications in aChanging Organization
Distance Holding Ruled by the OrganizationHealth Care Development
in the Future
This does not involve me To be forced into new systems Striving for efficiencyNot seeing any benefit
of the changesThe person’s will of taking
responsibilityLooking at the coming changes
with some curiosityThe others, not us Technology contra being near Creating new needs for increased
health care consumptionBorder between organizationswill still remain New demands on staff to manage
Electronic Applications and a Changing Organization 211
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The theme identified in the group discus-
sions was: Taking a standpoint today in rela-
tion to the past. It became clear that the staff’s
experiences with previous development work
and different kinds of projects had a strong
impact on the informants’ expectations. Bytelling stories about what they actually knew,
and speaking of their past experiences, they
motivated their actual standpoint and assumed
the outcome of the ongoing project. Infor-
mants seemed to be tired of one project fol-
lowing another, only a minority of which
could be described as resulting in permanent
change. They could not identify a clear justifi-cation for the actual project. In this reasoning,
they regarded their everyday practice and the
variation of patients’ or clients’ needs. The
seemed to indicate that most of the staff could
not see the possibility of their influencing this
project even if this was an intention of the
overall project. We also interpret a concern
and fear that vulnerable patients or clientscould be disfavored in the project. Because
of this, the informants had an overall opin-
ion to be skeptical of new projects and also
this present project of which this study is a
part. This skepticism also resulted in a criti-
cal approach and a sense of who actually
would benefit from this. However, there is
a thread in the text about the staff accept-ing new projects because projects are a part
of today’s work, and they still hope that per-
haps a new project will result in positive
changes.
Distance holding
This does not involve me.
Informants described how they distanced
themselves from the actual project. They did
not feel support from the leaders and felt
they were not getting information or being
invited to attend meetings about the project.
Not feeling support from leaders had a neg-ative impact on their views on the forth-
coming changes, as group 1 expressed the
following:
4) . . .The ones higher up [management]
haven’t given any information.
5) Then at the same time, I think we are
so used of not getting any information that
we hardly react anymore,
4) We haven’t even thought about it
[information on the project] because somuch
is going on, and we never get to know about
anything.
1) No, it’s all so silly (group 1).
Discussions about everyone’s involvement,
the intent from the project group and lead-
ers, came forward, but informants could notsee this actually happen. Informants pointed
out that they hardly had gotten the permis-
sion to attend the actual group interviews.
This was something substantial for them to
demonstrate a concrete example of their feel-
ings of exclusion. They expressed how they
did not think about the forthcoming changes
because there was no use to be preoccupiedbefore knowing the changes actually would
take place.
Not seeing benefit of the changes
In the group interview, it was obvious that
informants had difficulties seeing the useful-
ness of the applications that had been pre-
sented to them. They pointed out that the
kind of tasks they performed in their every-
day work cannot be replaced or would not besupported by electronic applications, for ex-
ample, the need of being physically near the
patient/client. Informants considered their
work as one where face-to-face encounters
were irreplaceable expressing the need of
continuing to work in that manner. Opinions
about how the electronic applications might
be a hindrance in their work were expressed:
1) Our work often implies the need of
touching the person and being able to see
the person from different angles and in 3
dimensions; we also need to see them move
in the room, and that’s damn hard via an
interactive media (group 5).
Informants provided examples of issues
they rather would have seen being addressed
212 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and described the actual project as a funny
thing, emphasizing they would have preferred
other improvements. Some of the staff were
astonished by the actual project and how they
had perceived the project’s purpose. The proj-
ect did not make sense because its directionwas the opposite of the leaders’ information
only a few months earlier based on new rules
from the county council.
The others, not us
A majority of the informants stated that
someone other than themselves could bene-
fit from applications developed in this proj-ect. There were numerous arguments that
other categories of staff, especially DNs (in
groups without DNs), were the ones who
would benefit from the applications The
others were also seen as staff in the munici-
pality (in groups with only staff from the
county council). Working together with dif-
ferent rules and separate laws was expressedas a big hindrance for cooperation, and the
staff from county council felt pity for the staff
in the municipality. Distancing from the proj-
ect was also seen in the discussions as focus-
ing on areas outside the project, which would
rather be an area for changes. Staff working
in geographic areas with long distances were
also seen as possible candidates to benefit frompresented applications, or staffworking in home-
based health care:
4) . . .I believe that staff from the mu-
nicipality will jump for joy for this, and they
might think these applications are super. They
can get in touch with the primary health
care center faster and have all their ques-
tions sorted out.
R) Is there anyone else who will benefit
from this?
2) Maybe district nurses.
4) I think the home care service staff.
2) And who are they supposed to contact
in the first place?
4) Well, maybe the ones who are working
in the patient’s home, someone who might
take a picture from a wound and send it to
the district nurse (group 2).
Ruled by the organization
To be forced into new systems
Informants discussed patients’ or clients’
freedom to choose and not be forced intonew communication systems within health
care. They stated that there would always
be persons having problems with electronic
applications for different reasons, such as
neurologically injured persons, persons with
dementia, persons with mental disorders, or
personswith drug addiction. Therewere ques-
tions regarding whether some of these groupsof persons are those that the health care cen-
ter wants to have on its list of patients. In-
formants also saw a risk of patients or clients
being forced to be cared for in a general rather
than individual way. They were unsure who
should be helped with new electronic appli-
cations. Informants meant that the ones with
the greatest need for care probably would bethe ones not receiving so much benefit of new
electronic applications, giving examples from
already implemented applications:
2) Yes they [patients/clients] must have
the possibility to choose.
1) It all must start out from the patients
needs and not from TES [planning system
in the municipality] (group 3).
Discussions about who, and if it even was
possible, would choose how care would be
performed came forward. Stories about how
patients’ homes were transformed into quasi
hospitals through medical equipment were
expressed. Informants wondered if relatives
and patients had the possibility to choose or
if dominant trends in society forced care tobe organized in a specific manner. Others
gave clear examples on how they had met
relatives expressing feelings of anxiety in pal-
liative care:
Electronic Applications and a Changing Organization 213
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3) I have had many discussions with the
palliative care team because actually not
all patients and relatives choose to be cared
for at home until they die, and we must
accept that, but sometimes I get the feeling
we almost should persuade and force them
to stay home even if they don’t want to
(group 2).
The person’s will of takingresponsibility
Informants discussed the willingness to
take responsibility in their work in relation
to the organization and ascertained that plan-
ning systems used in the organization thatare too rigid might create dilemmas for the
staff. Rules and regulations should be flexible
enough to let the person take responsibility
and react upon the actual situation; if not, it
can lead to frustration. The informants stated
that legislation31 recently being implemented
in the municipality limits their freedom of
action and has negative consequences. Staffresponsibility seemed to deteriorate with this
new regulation, giving negative consequences
for the quality of care. They felt they had no
support from leaders in seeing the patients’
need for flexibility:
1) And if we forget to log in to the system,
then we don’t get paid for that time, and it’s
the same there, we are humans.
4) You can forget the tool [a tool they
already use].
2) But we are not allowed to forget that’s
what they tell us.
4) No, they tell us we cannot forget.
4) We are still humans, and if a relative
stops me in the corridor and wants to talk,
you stay there, you don’t say, ‘‘No I have to
log in to the system first.’’
1) It’s terrible when they tell us that we
are not allowed to forget.
4) Yes, but we told them that if we visit
somebody and this person is lying on the
floor we shouldn’t care because we must log
in first because we must get paid for all
time spent.
1) Well, first of all, I take care of the
patient lying on the floor.
2) No, you must log in to the system first
(group 1).
The informants expressed a willingness to
take responsibility to prioritize care in regardto persons needing it the most. They feared,
and already had experiences with, more and
new implemented rules and regulations that
would reduce a person’s capability and will
to meet the individual needs of patients or
clients. The staff pointed out how fragile
many of the patients or clients are. An orga-
nization striving for standardized and effec-tive systems can jeopardize these persons’
need of flexibility. Different electronic appli-
cations have to be chosen carefully and seen
from patient or client perspective, capabili-
ties, and needs. Informants claimed that if
not, they are left with feelings of not doing
the best for the patient or client. Informants
discussed the importance of having rules andregulations that permit the individual staff with
some freedom and thereby take responsibility:
1) If freedom and responsibility are not
balanced with too many constraints and
regulations, the employee will go from being
a responsible person to an individual who
only follows the rule, if you are too top
managed you will not cope in the long run
(group 4).
Technology contra being near
In discussions, informants saw a risk of in-
creased isolation as a consequence of more
distance-spanning applications in health care.
One of the major reasons for increased men-tal illness, isolation, and loneliness in today’s
society was seen as a consequence of increased
use of distance-spanning solutions. Informants
believed that applications in the actual project
214 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
would not prevent this development in society;
rather, they assumed the opposite. There were
some discussions in which informants con-
sidered how it would be to live in a society
where technology took over. Informants ar-
gued that the meaning of direct contact withother persons cannot be replaced by technol-
ogy. Some situations suggested considerable
vulnerability of individuals. In one discussion,
some informants related the topic to their per-
sonal lives.
Informants pointed out that they were
aware of many complaints regarding the proj-
ect, and they also expressed negative thoughtsand anger toward leaders who did not under-
stand their everyday practice:
4) Yes, she [the manager] said that I must
log in to the system first, and I said to her
what do I do if I get reported for ignoring the
care receiver in need, can I send it to you?
R) What did you think and feel then?
2) Aggression.
4) I was also so angry after that meeting
of information.
1) Yes, as if the old person does not have
any value at all (group 1).
Border between organizationswill remain
Being in separate organizations while work
ing together was discussed; this was con-
sidered a problem yet to be solved. Staff rea-
soned how different legislations divided the
organizations, and this made everyday work
unnecessarily burdensome. Other borders,
specifically those between professions and
between different interests of care providers,were also considered as obstacles to the abil-
ity to do good work. These borders will al-
ways exist as long as caregivers working with
the same patients do not belong to the same
organization. Informants stated that one pur-
pose of this actual project was to improve
collaboration, but informants did not believe
this outcome would be realized. Informants
stated that it would be best for the patient or
client if staff were organized beneath in thesame organizational unit. These borders also
affected access of information;
4) . . .We must document in more than
one system because if the patient needs
hospital care it must be written in the
binder what has been done, and I try to
convince staff from social service to write
as much as possible in the binder instead
like they usually do, on simple paper. It’s
better if all documentation is in the same
system so staff at the hospital can have a
good overview of the patient; it’s absolutely
better (group 3).
Rules and policies between the 2 organiza-
tions were considered obstacles, especially
the ones that inhibited staff from performing
their daily work. Examples from how patient
care sometimes was delayed because of these
regulations appeared. Regulations also im-
plied that they were performing tasks that
were seen as useless or performing tasks sim-ply because they were told to.
Health care development in the future
Striving for efficiency
Also discussed was the belief that the future
would involve increased striving for efficiency.
The overall situation in society regarding the
economy was discussed, and worries about
the organization’s financial future came for-ward. Political decisions on health care came
up for discussion, including consideration of
how these strategic changes affected everyday
practices. Deputy staff’s situation had deterio-
rated, and the staff felt as if they were in a kind
of waiting room in a competing primary health
care sector. Some informants believed that
increased use of distance-spanning technologycould result in the dissolution of some profes-
sions. They also stated that men would bene-
fit in this development because a majority of
working technicians are men.
Electronic Applications and a Changing Organization 215
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Recently implemented legislation31 had
given staff a totally new way of looking at
patients. Meetings at which leaders informed
about the new situation with competition, free
market, and new concepts were mentioned,
and they described the actual situation in re-lation to the overall political situation. Based
on the legislation, patients were given a cer-
tain economic value for the health care center
depending on age, social status, and diseases.
Informants already saw a trend toward striv-
ing for efficiency:
3) . . .It’s more of a political discussion of
profit because we’re supposed to manage
this workplace with profit, and each patient
has a certain economic value (group 5).
3) . . .Since it’s not that you can choose to
not work with this, to run between different
patients becoming less efficient, you will not
be so popular [to the leaders] when they are
measuring how much we achieve everyday
(group 2).
Looking at the coming changes withsome curiosity
Informants stated that some changes were
exciting and that they wished their profes-
sion would further develop in some way.
Informants wished something would happen,
expressing a desire of professional develop-
ment. But at the same time, they describedtheir working conditions as not the best and
further stated this affected how they felt about
this ongoing project. They felt that it was hard
to be committed to the project. Although they
expressed some reservations, the informants
also expressed some curiosity about the future.
They expressed understanding of the leaders’
situation to some extent and saw the develop-ment overall in society as influencing everyone
involved in the organization.
4) . . .If it works out well with this project,
it’s really a positive thing for us.
(Mumbling took place in the group.)
5) Exactly.
4) But as we just said. . .
2) . . .It must be functional and easy to use.
4) Yes, it has to be really good (group 1).
Creating new needs for increasedhealth care consumption
Discussions regarding how health care cen-ters would be part of increased consumption
of health care came through. Considered were
the manner in which patient power could out-
play health care centers in their striving for
being chosen by patients and striving to at-
tract as many patients as possible and thereby
ensure economic stability. Comparisons were
made with the ways in which petrol stationshad developed from selling gas only to today’s
24 hours of accessibility and the possibility of
buying just about everything up to and includ-
ing pharmaceuticals. Each patient was seen in
the light of a certain economic value, and par-
ticipants agreed that in the future visits can
be created for economic reasons rather than
for health-related issues. Discussions of con-cepts such as ‘‘accessibility’’ and ‘‘producing
patients’’ were held, and informants ques-
tioned whether peoples’ overall health in soci-
ety would improve or worsen:
4) Accessibility can be good, but in some
way, there is a kind of breakpoint where ac-
cessibility can become consumption instead,
increased consumption, and that doesn’t auto-
matically result in better health; it’s like I
go to a candy store with a hundred differ-
ent kinds of candies, but then I know there’s
another candy store with 200 different kinds
of candies, but is it actually getting better?
(group 4)
New demands on staff to manage
New demands on the staff were considered
to be one consequence of coming changes in
health care. New pedagogical skills and waysof addressing patients’ questions were iden-
tified as one aspect of new demands. Infor-
mants established that in the future they would
meet already well-informed patients, many of
216 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
whom have access to information using Inter-
net Web sites:
1) Well, we see nowadays that both rela-
tives and patients have more knowledge
today; they have looked for information on
the Internet.
2) Or, they have had an interactive chat
with someone on Facebook finding out how
others have done, what they have taken
[medications] and so on (group 4).
Informants could see positive outcomes
from turning their own thinking 90 degrees,giving patients full insight to their own patient
records. Informants discussed attitudes in the
past toward so-called problem patients, per-
sons who had been regarded as difficult and
troublesome. The development of allowing
patients to possess their records would de-
mand staff to be more conscious of how they
created documentation in patient records.And they saw this as something positive for
both patients and staff.
Informants also reasoned that technology
per se has to be reflected on. By this, they
meant that every solution must go to the
proper patient and that not all solutions are
good or empowering for all patients. Infor-
mants also pointed out how distance-spanningconsultationswith patientswill require a higher
presence from staff members because the pa-
tient or client would not be physically near.
DISCUSSION
The intent of this study was to describestaff expectations prior to implementation
of new electronic applications in a changing
organization. Staff in this study were exposed
to more than one change at the same time;
this fact is reflected in the results. The motive
and extent of a change influence the staff at
different levels, depending on whether the
change is initiated by external or internalforces and whether the change is revolution-
ary or evolutionary. Staff in this study empha-
sized the changes that affected them at a
revolutionary level—new legislation and
competition—while the electronic applica-
tions affected staff on the evolutionary level.
The results of this study also provide broad
insight into how staff members depend on
previous experiences when changes are tak-
ing place. Looking back on past experiencesin relation to the overall situation in the work-
place can help motivate staff and better explain
their present perspective. The informants did
not see any benefit to the changes, and the
identified areas of improvement were not as
areas of real need. Despite this, staff wished
that their professions would develop and that
they could feel some appreciation that some-one at least attempted to do something for
them. Lewin32 and Alvesson and Sveningsson33
define the organization in its context, and
they emphasize what lies behind group be-
havior in organizations. Norms and values in
groups are of importance when changes
are taking place, and it is necessary to reflect
on this when change processes—which onecan claim are always underway—are to be
undertaken.
Relational and feminist ethics also emphasize
the contextual and the relationship of power
in the caring situation as well as in society
overall. The consciousness of a care receiver’s
vulnerability is considered as positive and actu-
ally needed for engagement. Ethical problemsthat emerge in face-to-face encounters are in-
separable from the organizational and social
settings under which they occur.34,35
Staff in this study expressed a willingness
to take responsibility, to rely on their ethical
sensibility when meeting a variety of needs
especially for fragile persons. Staff in this
study expressed frustration when they imag-ined a future in which more systems could
jeopardize their willingness to take responsi-
bility for the client or patient. Staff sensibility
and openness to care receivers, especially frag-
ile persons andweak groups, as well as to their
own needs, should be considered as their ex-
pression of relational ethics. Taking distance is
a way of coping with demanding situations,when there is a lack of possibilities of remaining
open and sensitive to care receivers’ needs.35
Kalvemark et al36 also came to a similar con-
clusion where staff showed negative stress
Electronic Applications and a Changing Organization 217
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
symptoms in situations where they could not
preserve all interests and values at stake.
Informants in this study expressed distance
to the project, and this can be interpreted as
being unsure whether the patients or clients
could benefit from new technical solutions.Other reasons for holding distance included
doubt as to whether the project should re-
sult in permanent changes. Also, they felt
excluded from influence in the project.
Organizational and management ideas in-
spired of the private sector often labeled
‘‘New Public Management’’ (NPM) have grad-
ually been introduced in health care organi-zations in Sweden like in other Western
societies.37-39 According to Dahl,40 NPM is de-
scribed as a hegemonic discourse based on neo-
liberal economics and logics of self-governance
and has its origins in management studies.
Bjornsdottir41 views how focus in organiza-
tions influenced by NPM has shifted from eth-
ical to economic discourses, and Waerness42,43
concept ‘‘rationality of caring’’ highlights the
tension between a caring and instrumental
rationality. Staff in this study emphasized how
the health care sector is changing direction.
Striving toward efficiency and marked values
change theway patients/clients are considered.
The staff saw a risk of increased consumption
of health care without increased quality of thecare. Also, new ways of communicating health
care and values of patients can distance patients
or clients from the staff.
Bergum and Dossetor35 point out that im-
plementation of technology often is touted
as time-saving and that health care has be-
come big business. This might contribute to
dehumanizing35,43 the patient or client rela-tionship because of the negative influence that
NPM might have on organizations. This is in
congruence with this study’s results when
staff members argue for the importance of per-
sonal meetings with patients or clients in their
homes and their concern about those who do
not have the capability or willingness to use
the technology. Waerness42,43 suggests thatthere is a need for time, less bustle, and
enough quiet to increase genuine, authentic
meetings between the patient or client and
the staff.
Staff related their reactions to this study to
their previous experiences, and overall they
were skeptical toward the project. They were
tired of being subjected to one project follow-
ing another. Ghaye44 suggests that changes in
health care organizations should ‘‘slow down,not speed up.’’44(p40) There is a need to slow
down, observe, and reflect to see what is really
needed. Only empowered staff can empower
the patient or client, and this presupposes
feelings of involvement and freedom.45 Study
results suggest that staff are not empowered
enough to support (empower) patients or
clients in the use of the new technology. Per-haps this at least partly explains why the
staff are skeptical of the project and of the
planned technical solutions and the future
that will bring even more technology use to
health care.
Lewin’s32,46 approach to understanding
group behavior in the field and his theory of
group dynamics provide insight into howbehavior and norms in a group need to be
taken into consideration in the process of
change. The organization is regarded as a
‘‘force field’’ where both changing and stabi-
lizing forces coexist. Nursing science could be
inspired by Lewin,46 who suggests that, to
reach a deeper understanding of group life,
there is a need for integrating scientific fieldssuch as psychology, sociology, and cultural
anthropology. In all groups, we find compli-
cated networks and conflicting interests.
Methodological reflection
In this study, group interviews were pur-
sued from an ethnographic perspective, withthe intent of creating an informal conversa-
tion and acknowledging informants as the
experts.47 Based on previous experiences,
informants preferred to talk about changes
in a larger context, and they might have felt
too insecure about the ongoing project to
make statements at this stage. The informants’
expressions put this project in a greater con-text, taking into consideration the political and
economic aspects in society. There is always a
risk of muting the discussion if the researchers
are rigid or stressed or if andwhen the discussion
218 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
doesnot take the expectedpath. Theseproblems
were avoided in this study by using an ethno-
graphic approach.
Conducting research group interviews re-
duces the informants’ sense of being studied
objects; the researcher sets the climate forthe discussions. One of the researchers at-
tended as many meetings about the project
and the electronic applications as possible
with staff in order to become known and rec-
ognized among staff before the interviews.
Rigor and bias, according to Hewitt,48 mean
active reflection upon one’s own social posi-
tion. Appearance and use of language are ofimportance in this reflection. In meeting the
staff, careful reflections on own physical
appearance and striving to use an informal
‘‘everyday’’ language were important.
Because the informants in this study
were part of an organizational change, and
this research study aimed to study this
change, interviews were held during work-ing hours. Thus, participation might have
been regarded as a duty by some informants.
But all group discussions lasted at least
75 minutes, suggesting a need for these
discussions.
CONCLUSIONS
Staff involved in this study were undergo-ing simultaneous changes. The focus of each
group was clearly on the changes that affected
them at a deeper psychological level, placing
the organization in a totally new competing
situation. Staff were aware of the fact that
changes are a part of their daily work. They
expressed distance from the actual project,
which aimed to implement electronic applica-tions, despite the enthusiasm about getting
everyone involved. The staff expressed ethical
sensitivity toward clients and patients and
feared diminished freedom in work and in
efforts to meet a vulnerable person’s needs.
New restraints on staff do affect the caregiving
process. Managers should consider whether a
given change is revolutionary or evolutionaryand take action in the change process accord-
ing to the possible psychological impact the
change might have on staff.
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220 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2012
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Paper II
Journal of Health Organization and ManagementDigital support for medication administration : A means for reaching the goal ofproviding good care?Andersson Marchesoni Maria Axelsson Karin Lindberg Inger
Article information:To cite this document:Andersson Marchesoni Maria Axelsson Karin Lindberg Inger , (2014),"Digital support for medicationadministration ", Journal of Health Organization and Management, Vol. 28 Iss 3 pp. 327 - 343Permanent link to this document:http://dx.doi.org/10.1108/JHOM-11-2012-0222
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Digital support for medicationadministration
A means for reaching the goalof providing good care?
Maria Andersson Marchesoni, Karin Axelsson and Inger LindbergDepartment of Health Science, Division of Nursing,Lulea University of Technology, Lulea, Sweden
Abstract
Purpose – The purpose of this paper is to describe staffs’ perceptions of digital support formedication administration (DSM) and out of the perceptions interpret underlying values.Design/methodology/approach – In total, 22 persons working in elder care participated in thestudy. The study had a qualitative approach and focus group interviews were used to collect data.To analyze the manifest content a phenomenographic method was used. An interpretation ofperceptions was then undertaken aimed at identifying underlying values.Findings – Three descriptive categories, “utility,” “impact on working environment” and “economicimpact” were the result of the manifest analysis. The values of having a “good working environment,”“benefits” and “good economy” were interpreted as guidance for staffs’ acceptance or rejection ofthe DSM.Social implications – The care-giving process and its challenges from the perspective of the staffsneed consideration. Staffs in this study sometimes expressed strong emotions as a sign of frustrationfor losing prerequisites to perform their work well. In big complex organizations where economy andeffectiveness are often discussed, knowledge of power relations in innovation and implementationprocesses would be beneficial. Although moral distress is a well-known phenomenon, future researchmay be needed to find solutions that diminish this negative trend in more economic focussedorganizations.Originality/value – This study had a twofold approach with the intention of going beyonddescriptions. To gain a deeper understanding a normative interpretation was completed. Ethicalconflicts are frequently characterized as conflicts between at least two values. In this study staffsexpressed fear of losing prerequisites needed to perform their work well. Prerequisites that wereidentified as values and these values were threatened by the DSM.
Keywords Perceptions, Values, Elderly care, Communications technology,Medication administration
Paper type Research paper
BackgroundThe purpose of this paper is to find out how staff, mostly registered nurses (RNs) andunlicensed staff at sheltered livings, perceived a tool aimed at support medicationadministration by using already existing technologies in a new way. A secondpurpose is to reach beyond descriptions and thereby we also intend to interpret staffs’underlying values.
Administering medication in sheltered livings in Sweden is a task mostly performedby unlicensed staffs, but also involves other categories of staffs. RNs working inmunicipal health care in Sweden frequently delegate medical interventions to
The current issue and full text archive of this journal is available atwww.emeraldinsight.com/1477-7266.htm
Received 20 November 2012Revised 21 March 2013
Accepted 26 March 2013
Journal of Health Organization andManagement
Vol. 28 No. 3, 2014pp. 327-343
r Emerald Group Publishing Limited1477-7266
DOI 10.1108/JHOM-11-2012-0222
The authors would like to thank all participants of this study. Conflicts of interest: None todeclare.
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unlicensed staff according to legislation (SOSFS 1997:14, 1997). Among these tasks isthe administration of almost all medications. Studies during the past decade havefocussed on reducing errors at the point of prescribing and dispensing medicationsat sheltered livings, on the amount of medications prescribed (Akner, 2005; Kragh,2004; Lau et al., 2005) and on improving the process from the pharmacist to otherhealth professionals (Lapane et al., 2005). Differences of perceptions and action due tomedication reconciliation in practice, with a focus on involved staff, showed that RNsand unlicensed staffs have a different focus. RNs tended to focus on the resident’ssafety and putting the “big picture” together, while unlicensed staff focussed oncompleting the task. Despite these differences, unlicensed staff can play an importantrole in identifying and communicating potential risks of harm (Vogelsmeier et al.,2011).
IntroductionThe Swedish welfare state, which includes sheltered livings for the elderly, haschanged direction since being influenced by the neoliberal trend of new publicmanagement (NPM). Efficiency and customer driven organization are forces behindthis management style where clear goals and service is accountable on behalf of theservice provider, are part of the discourse (Skalen, 2004; Vabø, 2009). According topoliticians, information and communication technology (ICT) can be a solution forfuture demands in health care, and is in line with NPMs’ vision of creating effectivebusiness-like organizations (National eHealth Strategy, 2010). ICT belongs to thebroader concept of eHealth that can be defined as “in a broader sense, the termcharacterizes not only a technical development, but also a state of mind, a way ofthinking, an attitude, and a commitment for networked, global thinking, to improvehealth care locally, regionally, and worldwide by using information and communicationtechnology” (Eysenbach, 2001, p. 2). The DSM in this study can be related to thisdefinition as a technical development of an already existing technology, a new way ofusing smartphones and computers in the process of administration of medications atsheltered livings. Also, it can relate to the definition by its demand on staff to accept away of thinking about their work that by history and tradition is considered bodywork(Twigg, 2000).
Many studies have described staffs’ views and perceptions on ICT in general(Engstrom et al., 2009; Lindberg et al., 2005; Nilsson et al., 2008; Savenstedt et al., 2006;Varpio et al., 2009; Walivaara et al., 2011). Some have focussed on the organizationalconsequences of ICT in telemedicine (Aas, 2001, 2007) and elderly care (Vimarlundet al., 2008). A literature review highlighted advantages and disadvantage from staffs’perspectives on ICT (While and Dewsbury, 2011) and on nurses’ new professional rolesand difficulties when they are given the task of installing telehealth technology, forexample (Starren et al., 2005). Staff in elderly care has little experience of working withICT and this might contribute to difficulties in expressing needs and requirements ofany ICT system (Scandurra et al., 2005). A similar conclusion was drawn by Jansson(2007) as care staff became silent and had difficulties to explain their embodied andsituated knowledge as to explain demands on new technologies. Jansson (2007) is alsoarguing for participatory design when developing new technologies although sherecognizes that this not always is easy to achieve.
The caring practice is embedded in an environment that is political and public butalso intrapersonal and intimate (Tronto, 1995, 2010; Twigg, 2000; Waerness, 2005).It is a practice mostly performed by women (SCB, 2007). Contextual factors, such as
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different people’s interest in the situation, social norms and cultural attitudes, orexternal political and economic factors influence the caring practice and also have aninfluence on ethical dilemmas that occur. In this it has been found that policy makersought to recognize that values have an impact on decision making and that thesedecisions should embody values which are at least similar to those held by the broadpopulation (Clark and Weale, 2012).
As mentioned, introducing ICT in health care has shown some ethical concerns.Staffs in residential care communicated mostly negative attitudes toward ICT. Theybelieved it would be difficult to use, would increase the risk of an inhuman care andthat the ICTwas not user-friendly (Loh et al., 2009). General practitioners in homecareurged caution when introducing ICT and stressed that staffs must not be seen asgatekeepers. According toWalivaara et al. (2011) there are central values in health care,such as personal encounters, that ICT cannot replace. The relationship between staffand patient might be challenged when using ICT, and there is also a risk ofmedicalization of the home environment (Demiris et al., 2006). Munck et al. (2011)showed that district nurses become vulnerable because of increased demands whenintroducing new technologies in palliative homecare. Managers and technicians needto bear in mind that staffs might have ambivalent feelings toward ICT and a fearof developing a tendency toward inhuman care. Ethical discussions among staffconcerning possible consequences, such as fear of developing inhuman care, may befruitful to highlight different views on planned ICT (Engstrom et al., 2009). Managersmust be sensitive to these ethical concerns (Andersson Marchesoni et al., 2012) andelucidate the advantages and disadvantages for the caring practice and demonstratean understanding of the value of caring, different actor groups’ interests and valuesshape the development process of an ICT system (Hedstrom, 2003, 2004).
Values tell us what is desirable, good, bad, better or worse than something else(Badersten, 2006). Values serve to justify our standpoints and the way we choose to actin different situations. Values can be of a general character or specific in nature. Valuescan be divided into hierarchies of intrinsic and extrinsic values. Intrinsic values aregood per se – they are independent and favorable in themselves regardless of externalfactors. Extrinsic values do not stand by themselves – they stand in relation tosomething else that is perceived as good or desirable. Extrinsic values are sometimesreferred to as relative or secondary values. Extrinsic values are desirable due to theirconsequences. A criterion for distinguishing a value from a personal opinion is that avalue has an intersubjective validity. It must be desirable by more than one person(Badersten, 2006).
This background shows that descriptive studies of how staffs perceive ICT havebeen done on various perspectives and contexts, but to understand staffs’ perspectivesit might be suitable to go beyond descriptions. Therefore this study is an attempt toreach a deeper understanding, by taking a step further and interpreting empiricalfindings. Consequently, the aim of this study was to describe staffs’ perceptionsof digital support for medication administration (DSM) and out of the perceptionsinterpret underlying values.
MethodsDesignA qualitative design with a phenomenographic approach was chosen to describe staffs’perceptions of the DSM. Phenomenography is not intended to uncover what a specificphenomenon is, but rather the various ways that people perceive or conceptualize a
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specific phenomenon. In health care research it is essential to distinguish qualitativedifferent ways of how a phenomenon is experienced and understood; of interest is thesubjective knowledge (Barnard et al., 1999). An essential aspect of this methodology iswhat Marton (1981) calls the first or the second order perspectives. Applying the firstorder perspective means to describe the reality of a phenomenon. Applying the secondorder perspective has to do with how the phenomenon is perceived by someone.To interpret underlying values a normative approach was undertaken (cf. Badersten,2006).
ContextSheltered livings in Sweden. Access to sheltered livings in Sweden is given accordingthe legislation SoL 2001:453. When a person has caring and/or physical needs thatcannot be met in their ordinary home, with the maximum assistance by home helpservice staff, the person can get admission to a sheltered living with 24 hours of staff athand. Persons living at shelter livings therefore often have a complex combination ofsomatic, social and/or cognitive needs. Care work demands that staffs provide qualitycare based on democratic grounds and that staffs promote social security for theresidents. Staffs also have a responsibility to emancipate and develop the capabilities ofboth individuals and groups. The resident should have the ability to live independently insafe conditions and have an active and meaningful existence in community with others(SoL 2001:453, 2001).
The research study. This research study is connected to a development project aimedat innovate future work practices by developing and introducing digital solutionsfor use in health care. The project involves one health care center and two shelteredlivings in one municipality. This paper covers staffs from the municipality. Staffs wereinvited to participate in workshops, led by a project leader with ICT experience.The authors of this study passively attended the workshops. Workshops wereconducted during autumn 2009 aimed at finding areas where digital solutions couldsupport improvements for future health care. Using workshop data, the project leaderelected to find a digital support for medication administration (DSM) from variousareas ripe for possible improvement. The development of the digital solution took placein 2010 and parts of staffs were periodically invited to test and evaluate the DSMduring this process.
The digital solutionThe DSM is a personal digital tool (smartphone) which wirelessly connects to thepatient’s record and automatically uploads their medication prescriptions. It is notuncommon for people to have an average of 10-14 prescribed medications based ontheir diagnosis and treatments. The DSM is aimed at providing a safe and individualhandling of the prescribed medications for each person. The quality of administratingmedications is believed to be a positive outcome of using the DSM. A second belief isthat this tool could improve the status of care workers in society. With the DSM, RNswork with new software in their offices and on already existing computers while staffsat the wards handle the personal digital assistant aimed at replacing the traditionalpen and paper administration of medications.
Procedure and participantsThe managers for the two sheltered livings involved in the project were informed aboutthis study and asked for approval to continue. The first author gave information about
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the study at regular staff meetings and afterwards put written information and aninvitation to participate in each employee’s post-box. In total, 22 persons accepted therequest to participate in focus groups interviews (FGI) that were conducted betweenApril and October 2010 (Table I). The participants had between three and 25 yearsof experience of actual experience in health care. They ranged in age from 25 to 60.Because the FGI were conducted during the staffs’ regular working hours, the staffmanagers planned each group’s composition according to the needs of the on-goingactivities at the workplace. Before the interviews, each group was assured that thepresentation of the results would not contain any names or location thereby preventinganyone from being recognized. They were also informed that participation in thestudy was voluntary and that they could drop out at any time without givingany explanation. The Regional Ethical Review Board in Umea Sweden approvedthe project.
Data collectionFGI were used for collecting data. FGI is a way of getting access to people’s conceptionsand to collect data based on everyday knowledge (McLafferty, 2004). The interpersonalcommunication between participants clarifies different perspectives and/or valueswithin a given cultural context (Barbour and Kitzinger, 1999). A low structuredinterview guide for discussing different aspects of the DSM was used to support theinterviews. Questions like “Tell me what you think about the DSM?” and also “Tell mewhat can be positive with the digital support or what could be a hindrance?” were partof the interview guide. At the beginning of each FGI the first author emphasized thatall kinds of expressions were of interest, and that there is no such thing as right orwrong. The groups were encouraged to think aloud and reminded that doubtful orcontradictory feelings or expressions were acceptable. Before each group interview, thefirst author reminded staff about the researcher’s role in the project and that it was notto be mixed up with project leaders or technicians.
All FGIs were conducted during the staff’s working hours and limited to 90 minutes.The first author was the moderator during all FGIs. The moderator’s task was toencourage informants to express how they perceived the DSM without restraint.The second or third author was present during three of the interviews. This persontook notes and assisted in asking clarifying questions. The actual length of the FGIsvaried between 75 and 100 minutes.
Data analysisPhenomenography. The interviews were recorded and the first author transcribed eachinterview verbatim. The interviews were read to facilitate becoming familiar with thedata. All statements that contained perceptions about the DSM were identified and
Professions Group I Group II Group III Group IV Group V Total female/male
Care assistants 2 2 3 7/0Enrolled nurses 2 2 3 3 8/2Registered nurses 1 2 3/0Managers 2 1/1Total 3 4 4 5 6 19/3
Note: n¼ 22
Table I.Participants in the focus
groups interviews
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used to represent a short version of each group’s discussions. These statements werecompared to identify similarities and differences, and then statements appearing tobe similar in content were grouped together. A preliminary attempt to describe theessence of each group was made. The next step was to compare groups with regardto similarities and differences and then construct a final suitable linguistic expressionfor each group (cf. Dahlgren and Fallsberg, 1991). This resulted in three maindescriptive categories. The descriptive categories and variation of content arepresented in Table II.
Interpretation of values. Based on the empirical data, patterns from expressedperceptions were discovered. During the FGI staffs formulated questions andexpressed arguments for or against the DSM. Their arguments followed logic andsometimes they gave explicit reasons for different standpoints.
To understand the participants’ arguments both pro and con of the DSM, wedecided that this study would benefit from taking the analysis one step further. Thispart of the analysis was aimed at identifying underlying values and was inspired byBadersten (2006) and his normative methodology. The normative analysis is aimed athighlight the rational argumentation for a specific standpoint – in this study, howstaffs perceived and took a standpoint on the DSM. This analysis is normative sincewhat is desirable, and argued for or against, depends on what values are guarded orhidden, and what people value depends on contextual factors. It is not stable or fixed.Reflective notes that were written by the first author during the phenomenographicanalysis were read through by the three another’s. These were discussed by the threeauthors to facilitate the discussion and process of interpreting underlying values.This process was conducted with an awareness of the authors’ preunderstanding asnurses and researchers and these aspects were also discussed.
ResultsThe analysis resulted in three descriptive categories (Table II). Each category containsvariations that are presented beneath each descriptive category in Table II. Interpretedvalues (Figure 1) are based on the manifest content from the descriptive categories.
UtilityThis descriptive category embraces statements of certainty and of uncertainty regardingthe benefit and utility of the DSM. Descriptions are outspoken at general levels but also ata detailed and practical level. There are staffs who present opposite perceptions about theDSM. Staffs that were doing body close work did not see any benefits while staffs workingmostly outside the wards did perceive some need of the DSM. Staffs believed that if theresidents had been asked about their needs, they would have put forward other areas inneed of improvement.
Categories Utility Impact on working environment Economic impact
Variationof content
User-friendly or not Communication and relationsimproved and not
Economic burden for themunicipality
Increased qualityand statistics
Increased stress Companies will makemoney
Needed or not Exclusion and status We will not becomemore efficient
Table II.Descriptive categories ofstaffs’ different waysof perceiving the digitalsupport for medicationadministration (DSM)and variation of contentin each category
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Staff members thought the DSM would be hard to use in daily work and some pointedout the everyday practice and gave detailed descriptions on how the DSM wasperceived as impractical. They stated the importance of developing a system thatwas user-friendly. During these discussions, staffs argued that having to carrytwo units was not desirable and that the tool was too fragile. The tool could be brokenby falling or becoming wet. Another argument was that it was not compatible withthe existing alarm system. Also, more of their time would be required since theDSM was supposed to be more complicated to use than the actual performance ofmedication administration. Other statements were directly in opposition – the DSMwas seen as time-saving and having updated information always at hand was seenas practical.
All participants had some experiences of ICT and they mostly expressed negativityregarding a general mistrust in ICT. ICT was regarded as a complicated system thatrequired certain skills and support, and they were certain that the DSM was the same.Staffs also indicated concern that documenting the medication administrated only onthe DSM would be unreliable since the system depends on electricity. At a moredetailed level, staffs pointed out how the tool was impractical because it was too smalland it would be difficult to see what was on the screen. One question raised during thediscussion was if the DSM would be a substitute for today’s telephones. Staffsverbalized the stupidity of not integrating existing systems with the DSM.
Participants also claimed some positive outcomes while continuing to hold that theneed for the DSM was questionable. Participates stated that the DSM would increasethe quality of medications in general, and specifically stated that reducing the numbersof missed medications could be an improvement. This would reduce the negativestatistics on reports of divergences in medication administration. Other perceivedimprovements were that the RN could individualize alarms for all residents accordingto their needs or diagnosis, such as diabetes or Parkinson’s Disease, that require strictmedicinal therapy.
During the FGI, staff members asked each other whether they saw the need for theDSM, as they could not recognize whether or not it was needed as they consideredother issues more important. Medication administration was considered to be a small
Good care
Good workingenvironment
Benefits
Goodeconomy
Notes: The three values are grounded in staffs’ arguments in thedescriptive categories. The forth value, good care, is interpretedas the normative ideal of the caring practice
Figure 1.Interpreted values (n4)
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problem in the daily work described by staffs working at the wards. Staffs alsoperceived that the DSM would implicate double administration since the deputy staffdid not have access to any digital systems used. They expressed that it did not seemmeaningful to start using something that from the beginning was predisposed to beimpractical:
4; administrating meditations here is not a problem.
2; I think it is those who have the medical responsibility who see this as a problem becausethey are responsible for the divergences.
1; maybe they think that in their statistics over missing administrated medications it doesn’tlook good as they are responsible in relation to the national Board of Health and Welfare(group 3).
Impact on the working environmentThe working environment and relations between staffs, managers and residents cameforward as important issues in the staffs’ expressed perceptions. There are statementsbeginning with “not” and these are understood as the staffs’ ways of expressingsomething in opposition to someone else. This “someone else” stands for opinions thatthe staffs cannot share, a point of view that the staffs feel is an outcome of the DSM andthis outcome is not recognizable for them. Being excluded was also expressed implicitlyduring the FGI as these sessions also functioned to trade information between staffmembers; some participants were more involved in the project while others were lessinvolved.
Communication and relations between staff members and also between staff andresidents came up as an issue in the discussions. Some pointed out the necessity ofverbal interaction and how they feared that communication might deteriorate becauseof the DSM. Some participants believed the interaction between RNs and enrollednurses (EN) would diminish since RNs would administrate medication even more intheir office, sitting by the computer. Another consequence of this was that RN presencein the wards would be reduced. Staff members recounted negative scenarios wherethe residents would question if staff members were making private calls or sendingtext-messages during work.
Other more positive perceptions considered the interaction between medicationsand changes as the DSM should improve exchange of information between physiciansand RNs. Staffs working night shift regarded the DSM as an improvement since theysometimes had difficulties finding their colleagues to question which medication hadbeen administered or not. The DSM would provide information to residents and nightstaffs without depending on having a colleague near. A contrary perception expressedby a participant was that it is always better to talk face-to-face about issues and not tryto solve them by introducing new “computer systems.”
Staffs pointed out how the DSM would affect the working environment byincreasing levels of stress. One aspect had to do with learning something new, whenlack of time was an issue already. Staffs already experienced internal stress andbelieved that this would increase when relating to caring situations. The DSM wouldalso remind staffs when performing work inaccurately since the DSM provided alarmsat a precise time. This was also described as something that would affect staffsnegatively. Some of the participants also recounted how two different systems, onethat called for their attention from the residents and the other the DSM, would be
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inconvenient to wear and that it would be stressful having two tools buzzing in theirpockets. Adding to this, staffs expressed detailed concerns about how the tool buzzingin their pocket could affect the residents by increased levels of stress. They stated howit could contribute to feelings of irritation and gave explicit examples on how theymight act toward the residents. Some jokes were made as participants imaginedsituations where they would ask the resident to hold on since they needed toaccomplish pushing the buttons on the DSM before assisting them:
2; if you’re standing in the room of a person and this thing [the DSM] starts to beep they willget really stressed and you will also get stressed, you’re standing there with both your handsoccupied and you can’t silence this thing, and it only escalates beep beep beep, we alreadyhave enough of beepings here! (group 1).
Staffs stated that no one had asked for their feelings or if they saw a need for the DSM.They had experienced other projects and pointed out how they always got a finalpackage but were excluded from the process. They felt that no one understood theirsituation and that there was some person working higher up in the hierarchy who wasbehind these decisions. Participants described this with thoughts like “we always getsteamrolled.” They supposed their involvement in the project was due to democraticvalues that had to be followed, without any real commitment to let them get involved inthe process from managers or technicians. They expressed frustration since they feltthat the development of the DSM was out of their control. Discussions also regardedthe fact that ENs and nurse aids did not have much responsibility or participation inresidents’ medication administration or prescriptions and that these issues were onlydiscussed between RNs and physicians. Not knowing how and when staffs would beeducated or when they were going to test the DSM were other ways of expressingexclusion. Also, when staffs suggested any improvement for the DSM they felt anegative response from the technicians:
3; yes maybe that’s why we react because it comes from that direction [frommanagers] all thisand they never talk to us that works at the wards, it’s like we don’t understand anything.
2; yes that’s what they never do and it would be possible to avoid many stupid things[changes] if they just talked to us too.
4; because not all are stupid just because you work in the care sector.
2; I believe that’s just the way they think about us, it’s no use talking to us (group 5).
One purpose the staff perceived from project meetings was that technology in generalcould contribute to making the female-dominated care sector become more interesting,and the specific application was a way of attracting men to the caring sector.Staff members could not identify themselves with these statements made fromtechnicians, however, because to them, introducing the DSM was like “getting a slap inthe face.”
Economic impactThis descriptive category holds three distinctive variations of perceptions and is thecategory in which participants expressed some emotions. Safeguarding the overalleconomic situation for the municipality was identified as important. Issues about whowould make a profit from the DSM came forward.
Staffs considered possible economic aspects and asked themselves who wouldbenefit from the increased use of ICT at their workplace. These discussions were theones that ended in staffs expressing anger and frustration. During the FGI, staffs tried
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to figure out how the DSM could contribute to reduce costs for the municipality sincethey often were told that the municipality needed to reduce costs. Staffs expressed thatthe DSM was seen as an economic burden for the municipality and staffs could not seeany economic profit for anyone except the ICT sector. The DSM would become costlyfor the municipality since it would not simply consist of buying the system, but alsohave on-going costs as all ICT requires support and frequent adjustments. Thesediscussions ended up with expressions regarding the technology sector – at least thecompany that had made the application could have an economic profit, and that thereactually exists a growing market for all kinds of technologies:
4, but what about this medication tool, what are we supposed to earn on getting and usingthis, what can we really use this for?
2; you’re right.
1, we’ll see.
5; no, probably the ones that got this idea are going to earn money on this.
1; exactly, the municipality will get blown out of money.
4; yes I have never really understood that mathematics that anyone can come up with allkinds of ideas but if we come up with something we get banned for it right away, it’s just likeno no no, there’s difference between people and people (group 3).
The DSM was perceived as a tool for the municipality’s overall goal of becoming moreefficient. But staffs did not perceive the DSM to be a timesaver but nevertheless it couldrelease more time to spend with the resident. Staffs also assumed that no there was nopossibility to reduce the amount of staff members because of the DSM. Detailedcomparisons on today’s working procedure vs the DSM were made. Comparisonsended up with staffs’ concluding that the DSM could not help them save any time byany logic and that it would not make them complete the task faster. Instead, theypointed out that it would be a time-consuming process to learn how to use the DSM andalso that it required a time-consuming personal login. They stated that picking up thetool from their pocket had to be as fast as locking up a cabinet where all documents forthe current medication administration system were kept. These considerations endedup with the conclusion that time spent with residents would not increase.
Interpretation of underlying valuesThe arguments expressed by staffs regarding the DSM are the foundation of theinterpretation. In each descriptive category we found these arguments and thereafterinterpreted their underlying values. The four identified values are: good workingenvironment, benefits, good economy and good care. Not often explicitly spoken wasthe normative ideal of good care, but it was implicit in staffs’ arguments. The valueswere discussed in relation to each other, as they seemed to affect one another. Benefit isa value that sometimes is explicitly talked about and other times it is discussed asconsequences for both staffs and residents.
Staffs’ argued that a good working environment contained both goodcommunication and good relations between the staff members, among other things.The value of the working environment also incorporates features of psychologicalstress in relation to the residents. The urge for working in a good environment brought
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out aspects where the staffs felt cut out of possibilities to be influential participants.Our interpretation is that staffs consider the value of a good working environment as aprerequisite for good care.
A good economy is a value that staffs discussed to a large extent. Staffs reasonedthat the economy was connected to the DSM and they feared that the economy in themunicipality was somehow threatened by the DSM. They were well aware of economicrestrains that had to be done for the benefit of the future. A good economy for themunicipality is also interpreted as an important value and a prerequisite for good care.
Staffs had many questions about the need for DSM and if it could be beneficial fortheir work. In order to be beneficial the DSM had to be a better solution than theordinary routine used for administering medications. In this case, staffs had argumentsregarding both how it would affect the working environment negatively and also be aneconomic burden for the municipality; therefore, it was not seen as beneficial enough.Staffs did not see the need to improve the current performance of medicationadministration. Our interpretation is that their arguments were ways of consideringwhether DSM could support good care.
Benefits in relation to a good working environment and the instrumental valueof good economy were also discussed in relation to who would benefit. “Who” ismentioned in terms of staffs themselves, the residents, companies and the municipality.Staff questioned for whom the DSM would be beneficial and also who would be thebenefiter; in other words, who would profit from the DSM.
DiscussionThe result of this study has shown how staffs perceived a DSM. Furthermore,underlying values derived from staffs’ perceptions have been interpreted andconsidered to contribute to staffs’ acceptance or rejection of the eventualimplementation of the DSM. Our interpretation is that the value of a good workingenvironment, benefits and good economy are of great importance for accepting orrejecting the DSM as a means of reaching the goal of providing good care.
Staffs’ arguments regarding the working environment were in part made by usingexamples of how they were going to be stressed by the DSM and that the DSM was notuser-friendly. They thought that the tool would lack in utility for them. Staffs’discussions and arguments were founded in their own situation at the workplace andhow the DSM would affect the relationship with the resident negatively and also howrelations between colleagues were endangered by the DSM. According to Hoglund(2003) there is a connection between working in a good environment and highperformance of work. When demands on staffs exceed what is possible to do withoutbreaking policies and regulations, work becomes an act of balance. In the case ofbreaking rules that for instance are made for providing a good working environment,creates stress among staffs (Hoglund, 2003). Also Ahnlund (2008) concluded thatsupport and participation at the workplace in creating a good working environmentare necessary for creating good relations between management, colleagues and theresidents. Working in an environment that supports reflection and consciousness(about power, for example) are crucial for caring. Therefore, staffs striving toward agood working environment are signs of moral attentiveness since it demonstratesresponsibility and professional growth. This should be supported among staffs andby managers of the overall organizational setting of health care. Our interpretation isthat what is important for staffs is to have working conditions that support theprerequisites needed for the caring practice, and that this somehow could be threatened
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by the DSM. Staffs gave expressions of not feeling supported in values of importancefor them – values that supported the care-giving process. To create a good workingenvironment that support reflection and an ethical practice is of importance and willprobably improve relationships between colleges (Storch et al., 2009). In a continuouslychanging environment Goethals et al. (2010) suggests a leadership style where visionsare clear, goals are comprehensible and values are supported. Initially this processcould be facilitated by challenging normative ideas among staffs that the environmentactually can be changed to the better and to start communicating openly withcolleagues and also to seek support for this among other staffs in the organization.Power dynamics also need to be taken in consideration and everyone’s voice shouldhave the right to be heard (Storch et al., 2009).
The DSM was not viewed as a benefit to the work of staffs as it did not seem tofulfill the demands for the caring practice. In this study, staffs questioned the need forthe DSM – they did not recognize that there were problems with administeringmedications. Similar to a study by Hjalmarsson (2009) the purpose of a handheldcomputer for measuring time seemed complex and not understandable for staff.Hofmann (2003) questions whether there actually exists a technological paternalism.Positive arguments have been put forward both by the legislators (Ds 2002:3, 2002, p. 3;Berg et al., 2005) and also by project leaders in the actual project, that ICTwill improvethe status of care work and will attract young persons, especially men, to theprofession. In this way the legislators and the technicians in this study are telling whatthe problem is and how to solve it. Ideas about how technology in general is seen as asolution for many future challenges derives from engineers, scientists and expertsand might not be appropriate in the caring context. Hofmann (2003) claims thattechnologies in general are implemented without respect for the autonomy ofindividuals and without respect for context or fulfilling an existing need. Hofmann(2005) also argues for how technology relates to values in two different ways: first, itraises general questions about values, and second, technology is value-laden due to itsfunction. Technology in general has shifted from the initial thought of being a means toreach an end, to becoming an end in itself. Technology is always related to a purpose,and this purpose is based on something that is desirable for humans and wouldtherefore be highlighted and questioned. Will this technology be beneficial? And if theanswer is yes, for whom will it be beneficial? And will this technology give desirableconsequences?
The value of good economy was defined where staffs argued about how they sawthe DSM as s an economic burden for the municipality. This includes the perceptionsthat becoming more time and cost efficient was good for the economy. Argument fromstaffs regarding the economy was that the municipality would be losers and ICTcompanies were the ones gaining from the DSM. Economic advantages were by nomeans considered to be reachable for the municipality, and even less so for staffs andresidents. In this we interpreted staffs’ reactions to the DSM as expressions of fear oflosing prerequisites to good care, and this might influence on the motivation to care,the moral imperative required for caring. According to Austin (2012) commercialvalues such as measuring efficiency and streamlining organizations are demoralizinghealth professionals. This experience of frustration arises from a sense of failing tofulfill moral obligations to patients, their families and the public, whereas commercialvalues literally might demoralize health professionals (Austin, 2012).
Good care is interpreted as the normative ideal of staffs’ activity and therefore avalue that ought to be taken in consideration. This value is superior and considered to
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be good per se and is also the goal set up by the legislator. Our interpretation is thatstaffs argued this from this standpoint: “Did the DSM fulfill their expectations tobecome beneficial for reaching the goal of providing good care?” Our interpretation isthat the DSM was not beneficial enough to fulfill this expectation. This is important toconsider since the motivation to continue to care is negatively affected by levels ofstress, emotional exhaustion, work overload, lack of social support, and maybe mostimportantly, whenever a decline in care is perceived. Moral distress among health careprofessionals is a well-known phenomenon (Austin et al., 2005; Austin, 2012; Glasberget al., 2007; Kalvemark et al., 2004). Moral distress is a response of health professionals’frustration of failing to fulfill moral obligations inherent to the given fiduciaryrelationship with the public and the residents. An increased moral distress jeopardizesthe ethical engagement with the residents. Staffs’ ethical reasoning is essential forevery care worker, regardless of professional belonging. The ethical reflection relieson values, medical knowledge, previous experiences and consequences of choices in thespecific context (Goethals et al., 2010). Leadership based on theories that support avalue-based work culture is needed to sustain staff in the caring practice. Thereasoning and reflective organization should be encouraged as it probably will lead to amotivation to care as it supports intrinsic values for staff that supports theprerequisites needed (Moody and Pesut, 2006). Striving toward, and always reflectingon, what good care is about is crucial since this implicitly encourages staff to considerthe residents’ life histories, feelings, wishes and integrity.
The strong negative expressions and the frustration staffs sometimes expressedduring the focus groups can be understood as fear for losing something of relevancyfor them, i.e. good care. According to Lazarus’ (1991) theory of emotions, negativeemotions might get triggered in situations or changes that threatens values, needs orgoals that are of importance. Anger can also be a reaction to a real societal danger orinjustice. Strong emotions like anger are also different from other negative emotionssince the person feeling angry believes that things could have been done differently –that there were alternatives to the chosen path. Staffs in this study might have givenvoice to a frustration that regarded an overall constrained working situation. Thesefeelings were triggered by the project and the DSM. Expressing strong argumentsagainst the DSM was a response of staffs overall situation, a strategy for staff todescribe working in a strained organization. In this way, the DSM became a target, or aprojection, for this frustration. According to Lazarus, a normal reaction is to blamesomeone or something because we believe they have violated something we believe isimportant, and the anger comes from a sense of being out of control, while the blamedperson/persons are the ones in control (Lazarus, 1991).
Methodological considerationsThis study has two approaches: manifest and interpretive. For gaining transparency inthe analysis and interpretation, the process was done in collaboration between thethree authors and also discussed at an open manuscript seminar. The reflective noteswere part of this process, and these were written by the first author but all three hadaccess to them during the entire analysis. We considered group interviews mostsuitable for collecting data because of the positive aspect of this method to stimulateand widen thoughts that might not be possible to reach individually. One downside tousing focus groups is that they might impede some opinions that are not acceptable ina group setting since all workplaces are embedded in a culture built on collectivenorms. The authors of this study were aware of this and explicitly talked about this
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before each group session and participants were reminded during the interviews.There were groups that had opposite arguments and there were groups where staffssometimes questioned each other and this strengthens our picture of the discussionsas being open and dynamic.
ImplicationsThis studies results could be used as guidance for administrators, managers and staffsto start reflecting on and thereafter discuss values of importance when arguing for oragainst any suggested change. Values as a ground for the goal of an organization or aworkplace can be a starting point for discussing how, by what means, can we achievethe goal. Foremost, there is a need to identify and on democratic grounds overlook howthese goals are obtained. Also, the practical view of the staffs’ work needs to beconsidered when development work is performed – only they can offer the practicalinsight to how the introduction of any ICT solution will affect them. To elucidateand discuss values (extrinsic values) should be reinforced to create a physical andpsychical environment that supports the goal of staffs’ everyday work, to give goodcare (intrinsic value) to the residential living at the sheltered livings. Politicians andpolicymakers may be over-emphasizing the positive effects in their belief that ICTwillsolve future challenges in health care. Much more concern to the care-giving processand its challenges from staffs’ perspectives is needed, especially in big complexorganizations where economy and effectiveness is important. It is of great value toinvolve and listen to the staffs’ arguments for or against new technological solutions touse in health care. Concern to power relations and gender perspectives on innovationand implementation processes in municipality health care organizations might befruitful to explore furthermore. In fact, in municipality-based care, this might need tobe critically explored.
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About the authors
Maria Andersson Marchesoni is a PhD Candidate in Nursing. She is a Registered Nurse andholds a Master of Science Degree in Nursing. Her PhD project concerns health care staffsperspectives during a project aimed at develop and implement ICT in health care. The essentialinterest in her work is on ethics, but also on gender. Maria Andersson Marchesoni is thecorresponding author and can be contacted at: [email protected]
Karin Axelsson is a Professor Emeritus in the Department of Nursing at Health Science.Dr Inger Lindberg is a Senior Lecturer in the Department of Nursing at Health Science.
To purchase reprints of this article please e-mail: [email protected] visit our web site for further details: www.emeraldinsight.com/reprints
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Paper III
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Manuscript accepted for publication in Informatics for Health and Social Care
Going from “paper and pen” to ICT systems- Elderly care staff’s perspective on managing the change process
Andersson Marchesoni Maria*, Axelsson Karin*, Fältholm Ylva¤ & Lindberg Inger**Department of Health Science¤ Department of Work ScienceLuleå University of Technology, SE 971 87 Luleå, Sweden
Maria Andersson Marchesoni, RN, MSc, PhD studentKarin Axelsson, RNT, Dr Med Sc, Professor EmeritaYlva Fältholm, PhD, ProfessorInger Lindberg, RNM, PhD, Senior lecturer
Correspondence to; Maria Andersson MarchesoniMail address; [email protected]; +46920493873Division of Nursing, Department of Health Science, Luleå University of Technology, SE 971 87 Luleå, Sweden
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Going from “paper and pen” to ICT systems- Elderly care staff’s perspective on managing the change process
Andersson Marchesoni Maria, Axelsson Karin; Fältholm Ylva & Lindberg Inger
Abstract
Background: Lack of participation from staff when developing ICT has shown to lead to negative consequences and might be one explanation for failure. Management during development processes has rarely been empirically studied, especially when introducing ICT systems in a municipality context.
Objective: The aim of this study was to describe and interpret management experiences during change processes where ICT was introduced among staff and managers in elderly care.
Design: A qualitative interpretive method was chosen for this study and content analysis for analyzing the interviews.
Results: “Clear focus – unclear process” demonstrated that focus on ICT solutions was clear but the process of introducing the ICT was not. “First line managers receiving a system of support”gave a picture of the first line manager as not playing an active part in the projects. “Low power to influence” demonstrated results where both staff and first line managers came to the insight of having low contribution in the projects. “Low confirmation” represented the previous and present feelings of staff not being listened to. Lastly, “Reciprocal understanding” pictures how first line managers and staff, although having some expectations on each other, understand each other’s position.
Conclusions: Empowerment could be useful in creating an organization where critical awareness and reflection over daily practice becomes a routine. This could help in building a healthcare organization that encourages diversity and innovative staff, using the power and knowledge that already exists within the organization.
Keywords: municipal elderly care organization, ICT, qualitative study, management
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1. Introduction
Admission to elderly care facilities in Sweden is granted based on legislation [1]. A person with cognitive and/or physical needs that cannot be met in their ordinary home with the maximum assistance by home help service staff can obtain admission to an elderly care facility. Persons living at these facilities, therefore, often have a complex combination of somatic, social, and/or cognitive needs [1].
Despite the fact that ICT is recognized to have improved many of the processes in healthcare(e.g., by providing digital patient records and electronic consultations), the process of change can be troublesome [2] and slow [3]. There are several studies on success and failure related to the implementation of ICT [4-7]. Organizational management barriers — defined as changes in collaboration between healthcare teams, roles, rights and responsibilities — are one way ofexplaining the difficulties of implementation [8-10]. Some studies have concluded that staff attitudes and usability are obstacles to success and that they are due to lack of staff involvement in requirement analysis [4, 5, 11]. Others have focused on the needs and benefits of the technology; problems to be solved must be clearly stated, and the technology must be needs-driven [4] and beneficial because dysfunctional technologies can do harm [7]. Staff in elderly care has little experience with working with ICT, and this might contribute to difficulties in expressing needs and requirements of any ICT system [12].
Political decisions and legislation have had an impact on introducing staff to new electronic applications, and the driving forces behind changes sometimes blur and seem unclear [12]. Staff expressed that being part of a larger system and the use of ICT were inevitable for future growth[9]. They thought that competitive market-based values were one of the reasons for the emphasis on electronic applications [13]. Other studies [14, 15] found that it was difficult to implement ICT without suitable policies and legislation. Glaser [16] has pointed out some suggestions for management when introducing ICT; initiatives must have a clear purpose and involved managers must show commitment to the process of change. Forbes and While [18] suggest that nurses need to change from being passive to being active managers in the development of ICT systems.Abbot and Coenen [19] have pointed out that nurses unfortunately are often absent in the development process and, therefore, are left to deal with suboptimal systems. Furthermore, it is important to recognize that low contribution is a vicious cycle that needs to be broken [18].Hierarchical organizations often do not empower staff; transparency may not be available indecision making, and staff may be denied the opportunity to contribute [19]. On an individual level, external and internal demands and work control (i.e., making autonomous decisions) are related to self-efficacy. Self-efficacy refers to an individual’s belief in his or her capability to organize and execute a course of action needed to meet the demands of a situation. Job demands refer to the psychological stressors that exist in the work environment, while job decisions denote the workers' authority to make decisions on the job [20]. Lack of transparency and contribution in addition to low self-efficacy might lead to loss of job control and increase jobdissatisfaction [21, 22].
Although studies [17, 24] emphasize the need for a management perspective, the introduction of ICT has rarely been studied from a municipal perspective. Unfortunately there is a non-
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innovative climate in organizations responsible for elderly care. Managers focus on financialsurvival [25]. Research on how to develop optimal ICT that suits the work processes is needed [26]. Identifying the ideal leadership figure to execute ICT implementation has been shown to be important, but has also proven to be difficult [27]. Poor project management and organizational uncertainty are also issues that contribute to the failure of ICT projects [28]. McConnell [29, 30]described that first-line managers (FLM) and employees are more alike than different with regard to their daily work needs. Independent of their positions as first-line managers or ward staff, workers place the same demands on the organization in seeking job satisfaction and respond similarly to the behavior of their superior managers. Furthermore, McConnell [29, 30]claims that employees want recognition and feedback, and that it is doubtful that supervisorsbelow the level of executive management have any influence at all on changes in the organization.
Due to lack of management, usability needs, and poor technology performance, the implementation of ICT often fails. However, there is still a strong emphasis toward the increased use of ICT. Lack of participation from healthcare staff and first-line managers in developmentprocesses of ICT have shown to lead to negative consequences, which might be one explanation for the history of failure of many ICT projects. Additionally, this might contribute to jobdissatisfaction. Consequently, the aim of this study was to describe and interpret managementexperiences during change processes where ICT was introduced among staff and managers in elderly care.
2. Methods and procedures
This study used an interpretive qualitative approach based on data collected through individual interviews. The researcher is not considered a neutral observer, which, according to the objectivist view, remains separate from the research participants. Within the interpretive paradigm it is a common view that inquiry is always context bound, that all data should be viewed as value laden, and that knowledge is socially constructed [31] and mirrors a multiple and controversial world of different persons’ subjective way of experiencing the topic under inquiry [32].
2.1 Study context and procedure
All staff (n=12) and FLM (n=4) from two wards at two different nursing homes in one municipality were asked to participate in the study. They had been working on a project begun in the fall of 2009 that aimed to develop ICT systems to improve medication administration. In total, 13 agreed to participate (Table 1). Since only two FLMs agreed to participate, a second municipality that was currently introducing an ICT system was contacted for further data collection.
In the second municipality a key person assisted in identifying FLMs according to the inclusion criteria. This municipality was introducing a new ICT system aimed at planning staff’s work at the wards in addition to the computer-based documentation. Information about the study was given to the key person via e-mail in August 2012. The key person then e-mailed the information to all FLMs (n=9) in the second municipality along with a request to answer the e-mail if they
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were interested in participating. A second set of information was given to each person at the time of the interviews. From the second municipality, four FLMs agreed to participate in this study. A total of 25 persons from both municipalities were asked to participate and 17 accepted.
To gain detailed interviews reflecting the workers’ experiences, a purposive sample in congruence with Merriam [33] was conducted. The first criterion for participation was involvement in the process of changing working methods in a municipality context. The second criterion was that each person also had to be directly affected by the change and obligated to use the new system. The change was evolutionary, meaning that a previously existing method was developed by introducing ICT.
Nurse aides and enrolled nurses employed in one municipality’s health and social care organizations underwent work procedure changes that had previously been performed manually (i.e., by paper and pen). These working procedures had been substituted by the use of ICT systems. The ICT systems included 1) a computer software program for social record documentation, 2) a tool for administrating drugs with a smartphone, and 3) a computer software program to schedule care work for each employee at the wards. Staff had recently undergonetraining in using the computer documentation system. Although this research study was intended to focus only on that specific solution, the participants did not talk only about one specific tool;instead, they related all ICT changes to each other. Therefore, we decided to include these three different systems. The focus was on the process of the introduction of ICT and management.
There were no models used for implementation, but in the first municipality some workshops were conducted for finding areas that needed improvement and were solvable by ICT in a reasonable time (the project lasted three years). In both municipalities the ward staff was invited to test and express opinions about the systems under development. The first author of this study attended some meetings and training sessions with staff in one municipality one as a passive listener and observer. This author had extensive experience working as a nurse’s aide and later as a registered nurse in municipality health care. The role of the researcher was clearly defined and differentiated from the role of the technician and project leaders to all involved staff. Thisprovided a clear statement that all opinions, both negative and positive, were of equal value.
2.3 Data collection
Between December 2011 and January 2012, the first set of interviews was conducted, and the last set was conducted in the fall of 2012. Before each interview, 10-15 minutes were dedicated to providing information to the participant about the study. Two hours were allotted for each interview. This time limit was set in agreement with the department head who also gave the consent for the study. The interviews took place in a quiet room outside the wards or the first-line managers’ offices but still in the building of each person’s workplace. The interviews lasted on average 80 minutes, and the first author conducted all interviews. The initial questions included three areas: “newly introduced technology”, “gender”, and “caring practice”. Shortly after starting the data collection, we decided to include questions about the management of the project, since it seemed to be an important aspect to highlight from the participants' point of view. Participants themselves began to talk about the lack of information and the lack of clear aims in the project and why ICT was the solution to their problems. The interactive approach
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was chosen purposely. Participants were not treated as objects to be studied; rather, they were invited to the process as thinking and feeling people who could influence the process. In qualitative research the interviewer is the main tool for the investigation [32], and the interaction between the interviewer and the participants is highly dependent on the interviewers’ personality and skills [33]. In addition to the first author being the most important tool for the datacollection, an interview guide was used. We used open questions, and since interactions between the first author and the participants were ongoing throughout the project, the questions were of an evaluative and follow-up nature. One main question was: “To what extent have you been ableto have an impact on the change process?”
The study questions included the following: How does it work with the new ICT system? Has ithad any positive or negative effects? What’s working and what is not? Why the caring sector in contrast to the technical sector is still so female and male dominated?
2.4 Data analysis
A qualitative interpretive method was used to analyze the data [c. f. 34]. All interviews weretranscribed and used as a single text. Pertinent information was marked and used for analysis. The remainder of the text will be presented elsewhere. All interviews were then reread with attention given to the marked parts where the interviewee focused on the management of the ICT process. To grasp an initial understanding, a short summary of the marked parts was written on each transcribed interview. In the analysis, we not only looked for what was said but also howthings were presented. Looking for the how aspect of the data was also intended as a tool for interpretation. Text was then divided in smaller units, and codes were given to each text unit.Following the coding procedure, a first attempt at grouping the data according to content wasperformed. At this point in the analysis the question was raised regarding the two different perspectives (i.e., FLM and staff), and this was subsequently discussed. As both the staff and FLM participants had many similar experiences, we decided to separate only those parts of the results that differed. The grouping process continued by revising and regrouping the data until alogical sense of the data and a comprehension of themes could be reached. The regrouping wasdiscussed step by step among all authors, and the labeling of the final five themes was alsoperformed in a similar manner. The interpretation was inspired by Alvesson and Sköldberg, [34]using their description of elements in a reflective and interpretive process. The final themes were then reviewed to see how they related to each other and mirrored the process described by participants.
3. Results
The tables and text below present the collected socio-demographic data. Findings from the analysis of the interviews are intended to reflect an interpretive and reflective approach. The analysis resulted in five themes. Descriptions and interpretations are integrated parts in the text of each theme. To distinguish between the two perspectives, when needed, the reader of the results should know that “FLM” stands for only the FLMs’ perspective, while the usage of the term “staff” refers only to the staffs’ perspective. When “participants” is used, the intention is to reflect the perspectives of both the FLMs and the staff.
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Both Swedish municipalities had the same organizational structure with a political board. In both municipalities, the staff’s education level was the same: they had a two- or three-year high school education while the FLMs had a three year university education. The majority of the employed were Caucasian, middle-aged women.
Table 1. Descriptions of the participants and time-period for data-collection
Table 2. Interpreted themes (no. 5).
3.1 Clear focus – unclear process
To the participants, the management of the projects in the two municipalities seemed unclear, although the focus on developing and increasing the use of ICT systems indeed was clear.
Respondent (R): “He [the technician] did understand what I meant, but they did not seem to take it in consideration, because now it was all about this too. They only had this tool in their mind, and did not seem to take in other ideas” (staff, male, age 48).
R: “I’ve been thinking…where does it [the ICT system] actually come from? I have been working on it, but I don’t know where it comes from…
Municipality 1 Municipality 2
Time-period for data-collection December 2011-January 2012
October 2012
Total no of participants asked toparticipate (responding: yes/ no)
16 (13/3) 9(4/5)
Participants age (range) 25-58 44-64
FLM (male/ female) 2 (0/2) 4(0/4)
Staff (male/ female) 11 (2/9) 0
Total of participants 13 4
Themes
3.1 Clear focus – unclear process
3.2 First line managers receiving a system of support
3.3 Low power to influence
3.4 Low confirmation
3.5 Reciprocal understanding
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Interviewer (I): “You don’t really know”?
R: “No, not where it comes and why, from the very beginning, no” (FLM,female, age 64).
The technicians were considered to have technical skills and were regarded as “experts” or “the ones who know best”, and this was a common view among staff and FLM. By using a supportive approach, never being critical or asking critical questions, FLMs described themselves as motivators and facilitators. The FLMs played a background part from a decision-making point of view, and did not have a clear view on the process. Staff and FLM had common views, as they had sparse knowledge about how the systems worked or time plans for different activities. FLMsexpressed not being involved in making plans during the project. Some of the FLMs indicated that they were not involved at all in the development projects and missed information about ongoing activities in the project. One source of information for the FLM was the staff for whom they were responsible, as they kept them up-to-date with what was occurring in the organization.Overall, the staff was more critical of the project. FLMs, however, were more concerned with not being a bother to anyone. Participants’ expressions regarding the ongoing changes differed as they talked about the process from its very beginning until they became aware of the lack of clarity. Lack of good communication during the change process and the handling of the development work were both criticized.
R: “I do not dare to ask that question. We have had some meetings, but I never heard anyone saying that we will go on with the testing until the summer. We do get such confusing information, and I thought it would end by the end of this year. Have you heard anything else [asking the interviewer]? We [the staff from his ward] don’t know what is true; do you know?” (staff, male, age 47).
I: “If we turn back to the tool you are now testing, how much information have you gotten from your managers?”
R: “Nothing, she knows less than us [staff], and she is asking us for information sometimes or if we have heard anything” (staff, female, age 30).
3.2 First-line managers receiving a system of support
There were some positive expectations from the FLMs in regard to the ICT systems, despite the fact that the development was beyond their control and they did not actually know anything about functionality before starting to use the systems. The ICT system was a tool that would assist in organizational matters and issues by scheduling every resident’s interventions. This would reduce conflicts among staff regarding workload. There was also the belief that the system would make some work processes more transparent. Overall participants believed that the ICT system would improve the communication between the day and night shift staff and between staff and FLMs, as there were some strained relations, including a “bad attitude” and limitedunderstanding of each other.
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R: “It would be nice to have a system for communication between us and our FLM. We have enough papers laying around already” (staff, female, age 45).
There was also a history of conflicts (e.g., that regular staff sometimes took advantage of deputy staff and overloaded them with work or tasks that were too challenging). In these cases, some FLMs appreciated the planning system as a beneficial tool to improve the working conditions of all staff on the wards. One FLM described that when she came to the office in the morning, she often logged onto the ICT system to get an overview of how the work in the wards for which she was responsible was planned.
R: “We have this guy. He’s a deputy staff, and after we introduced the system he came to me and said that previously I was working much harder and now it feels like I don’t have anything to do. And I told him, you don’t know, but maybe your colleagues at the ward have been using you before unfortunately” (FLM, female, age 64).
In some ways responses suggest that the ICT system can support the FLMs’ roles by solving some problematic issues at the wards. It was also clear that the FLMs had not devised the plan of using ICT for solving these psychosocial issues. In other words, they passively received the ICT solution. Still, they did not question the introduction of the ICT system for structuring and planning some tasks of the staff, but rather they accepted it as a tool that might support their management role and help gain control over some psychosocial issues.
The overall interpretation of the FLMs’ descriptions regarding receiving an ICT system was that they assumed the system would support management, although the FLMs were not involved with specifying the system or its development. Receiving in this case also represents the interpretation of the FLMs’ limited likelihood of making autonomous decisions in the change process.
R: “I see this system as a tool for getting to know care receivers’ needs,and getting to know what staff actually do for each and every care receiver and what they actually do at work. Then the system might show that we need more staff, that the needs are that big, or that we can relocate resources from another department. It’s a planning system that makes everyone knowwhat one has to do during ones’ working day, and this might contribute to less disputes among staff” (FLM, female, age 62).
R: “It was actually aimed for home healthcare from the beginning as a measurement for quality and time. Politicians have decided that 85% of the time in this system must be time that the care-receiver gets” (FLM, female, age 54).
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3.3 Low power to influence
This theme provides a picture that both FLMs and staff experienced a low influence in the development process, but in different ways. Staff expressed that they were active in the beginning of the project but had come to realize that their involvement had a low influence onboth identifying solvable problems and later system development. When they realized that they actually had minimal power to influence the process, they started to think about decisions in the projects. Participants also articulated how past experiences of limited power of influence on daily work negatively affected them.
R: “Someone should listen to us—the staff. Now it’s like we are not credible persons. It’s like we are some kind of second selection of people” (staff,female, age 55).
R. “No, but as everyone knows, no one listens to a woman and women in general have gotten used to that fact. It has always been like that, and it will always be like that. But if something like this happened at [mentioning a male dominated workplace in a city nearby], they would just refuse” (staff,female, age 52).
The importance of being listened to was repeatedly emphasized in the participants’ descriptions. The importance of being listened to and beginning to have unanswered questions can be interpreted as the participants’ feeling limited power. This has been interpreted as crucial in the whole change process, since something happens with how participants express their experiences of the management. As questions started to rise about the project, indicating a lack of clarity and information during the change process, responses, especially from staff, were enunciated using strong words and criticizing the municipality’s organizational management. Both FLMs and staff started to raise more and more questions about the purpose, or “the real purpose” as some mentioned, for the change processes. During some of the interviews, questions were asked about why and how the ideas of the ICT system had come forth and how these solutions were motivated. They wanted to know why these projects were undertaken and why ICT systems were seen as solutions. Some FLMs pointed out the importance of understanding the reasons behind any change and were also very open and honest, even when lacking knowledge or information about reasons. It seemed as participants expressed that trust in decision makers was at stake,because purpose and benefits of the projects were unclear.
R: “The negative with this project has been the lack of usability of the ICT system. It has been bad. Then, staff were involved from the beginning, but after some time all the focus was on registered nurses’ work and then we all forgot to involve staff from the wards”.
I: “To get their opinions”?
R: “Yes, exactly. They were only invited at the beginning, and I think they never understood the purpose of this project. Another negative thing was the
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choice of issue to solve, because we had many other issues we needed to get solved” (FLM, female, age 44).
The participants began to realize that ideas they had come up with during some creative workshops did not influence the development of the ICT system at all. Low power of influence was also seen as participants started to use the ICT systems that sometimes lacked in performance. Technicians were held responsible for the lack of feedback, because they were responsible for the technical development from the onset of the change process. Trying to stay committed and continuing to use a system that lacked performance, and was not even purposeful,or needed, was described by some as difficult. Participants indicated that during the hands-ontesting of the technology, it was important to receive feedback on how the development of the ICT system was progressing. Being involved and motivated to proceed with the test also depended upon constructive feedback, and there was a lack of positive communication during the project.
The fact that staff at this stage realized they had low influence is interpreted as a trigger of negative experiences from the past. The ongoing changes were related to a history of never being listened to by the organizational management, and this feeling was triggered by the lack of clarity during the ICT projects.
3.4 Low confirmation
A history of not being confirmed and lacking feedback with low possibilities to influence, in general, was a part of staffs’ previous experiences. Going from a positive experience to starting to raise questions made the staff realize that they once again had a low possibility to influence.This seemed to trigger strong feelings from similar experiences from the past and led the staff to discuss past stories where they felt offended and betrayed from the organizational management.Their criticism was harsh and emotional. Low support and lack of feedback came forth in quite similar portrayals as the numbers of interviews increased. These narratives were emotional and the use of strong language and feelings of betrayal by organizational managers, as well as not having support from anyone, was part of these narratives.
R: “Politicians don’t listen to what women say even if we have some female politicians too. But even so, they don’t listen and this goes for the municipality management too. No one listens to us; they just decide over our heads and that doesn’t work” (staff, female, age 58).
R: “For instance, if they [municipality management] want us to be more positive to this kind of technology project, they must learn to listen to us.Either you get into a positive spin or a negative one. If we get into a positive spin, we surely would be more positive, also about changes. The municipality would gain by giving some positive feedback toward us. It is so much wiser to give something positive, because then you get more loyalty from staff” (staff, female, age 45).
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R: “I wish we would get more positive feedback from the employer” (staff,female age 47).
The descriptions seemed to have an impact on the staffs’ views of the ongoing work. Several of the participants mentioned meetings in the past and arguments that had been put forward by politicians or “the ones up there”. The same arguments had also been used by some of the technicians involved in the projects. What irritated participants was that arguments, regarded as the beneficial aspects of using ICT systems, did not picture the reality that was the care workers’everyday experience. Also, participants mentioned that few of the politicians and “the ones higher up” had insight into the nature of care work.
Staff were not always clear about from whom they actually lacked confirmation. When participants discussed the lack of affirmation, they mentioned “politicians”, “society”, or the “ones higher up”. This might be a sign of their not wanting to point out a specific person or position, or it may be a reflection of the management as complicated and distant. It might also be due to the fact that both the staff and the FLMs expressed that the position of the FLM is adifficult one.
The surrounding society is also important in terms of confirmation. Many of the staff involved in the development work claimed that “the ones higher up” and the politicians “do not listen towomen”. They stressed the need for being listened to and being recognized as experienced working women with a great deal of diverse knowledge. They considered their knowledge to be lost when no one asked for their opinions or listened to them. They expressed the need to look outside the organization for problem solving or for expertise in development work. They seldom considered the potential within the organization. When speaking of these issues, they seemed resigned.
“One gets burned-out. I feel that I’m getting sick and tired of our situation and no one is listening, because at work I’m always in a hurry and always taking care of pee and poo; that’s what I do all day long. We don’t have time to do anything else. It makes me lose the joy of work” (staff, male, age 47).
3.5 Reciprocal understanding
The participants showed understanding for each other’s situation in their different roles and recognized that it had been hard for both the staff and the FLMs to have any influence at all inthe ongoing project. Both staff and FLMs had some understanding for the FLMs’ difficult position both on a daily basis and throughout the project. However, there were also expressions of disappointment toward one another, because there were expectations and wishes left unfulfilled (e.g., wanting to be listened to and given feedback).
The FLMs’ position was recognized as difficult, because they lacked knowledge and information at times about the ongoing projects and did not act as leaders in relation to the project. It also seemed a common opinion that the position of FLM indeed held few possibilities for makingautonomous decisions.
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R: “The FLM is afraid and they often hide behind arguments like ‘I must do this; it’s my duty’ and the FLM manager doesn’t have any power at all (staff,female, age 52).
From the staffs’ viewpoint, the FLMs simply did what they were told to do by their superiors. The FLMs tried to maintain a difficult position in which they were expected to balance several people’s demands: to keep staff, relatives, managers and “higher ups” content while maintainingorganizational standards.
Although participants in this study, both the staff and the FLMs, had some criticism toward each other, they showed a lot of understanding for the others’ positions and in particular the FLMs’position. It appeared that the FLMs and staff reciprocally understood each other, where staff lacked motivation in using the ICT systems and FLMs lacked information and authority to make decisions for the projects. The FLMs described that there had been previous similar projects that had been poorly handled, and the lack of information was common. The FLMs recognized that some staff were offended by these projects, because they felt the systems were meant to control poor work performance. One of the FLMs came forward with thoughts about the difficulties in even trying to blame someone for things going badly in the project. It seems as if these insights gave participants the feeling of resignation.
R: “They [the staff] had opinions, but I don’t think they ever understood the main purpose with this project. They were not involved from its very beginning, so how could they (FLM, female, age 44)?
R: “There is always someone who is afraid of changes and those who like to be challenged, and those are the ones that know why they are at work. Sometimes we all need to remind ourselves why we are here [at work], especially some need to be reminded. But I must say that I have many really competent workers here” (FLM, female, age 62).
Overall, there were many participants in this study who were concerned with the FLMs’position; it was described as “being in between”. The position of the FLM was described as just a small brick in a much larger system. Staff viewed the FLMs as “marionettes”, being without any power, and being fearful. FLMs themselves recognized that their position was not easy, and they relied on their previous experiences from working as registered nurses or enrolled nurses.
One FLM was eager to show that, to her, there was no prestige in admitting to her staff that she sometimes lacked knowledge and information about the ICT system and also about the change process as a whole. She was proud of these insights that gave her the courage to be honest.Although FLMs stated that there had been some questioning during the process, they also expressed pride in their staff.
R: “It’s not easy to be a manager either, I do understand that. They have their directives to follow. But sometimes they should think a bit more, because it’s always ‘no’, whatever we say or need” (staff, female age 45).
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4. Discussion
The overall understanding of the results was that both staff and FLMs had a low power of influence and mostly assumed the role of recipients of the ICT system. The purpose and decisions about why the change was initiated were unclear. Also, there was a lack ofmanagement of the projects. It was not clear who was responsible or for what. Both staff and FLMs described similar feelings, including frustration and irritation and were accused of changesthat they had not decided upon and did not know much about. However, it needs to be clarified that FLMs did not express the same strong harsh feelings as the staff. Interestingly, and similar to the conclusion found by Jansson [35], we found that participants thought that politicians have a strong belief in the benefits of ICT—arguments that did not picture the everyday realities met at work. Many participants communicated that the ICT solutions were not significant; rather they solved problems of minor improvements for low priority issues.
The results in this study showed diverse opinions of the nonexistence of project influence and not being listened to. The participants felt powerless and disempowered. The opposite, of course, is the feeling of empowerment, and this concept can be seen as a goal in itself (e.g., in patients striving toward better health). It can also be described as a process for individual growth or as avirtue and an ideal in ethical theories [36-38]. By saying this, we assume that empowerment is desirable, although it should be recognized that not everyone wants to be empowered and that employees have vested interests and different value systems [37].
Empowerment has been described from a psychological individual perspective or a managerial perspective whereby those in power share their authority with those lacking it [38]. The psychological perspective of empowerment is based on people’s internal cognitive state of motivation, and feeling high intrinsic motivation empowers people. This means that a high degree of empowerment will be fulfilled if the person feels competent, can make independent choices, and can make a difference in performed tasks. In addition, this leads to a feeling of meaningfulness that also empowers the person and will result in improved quality of care [38].
Another way of understanding empowerment is from a critical societal group perspective [41] or as an ethical value in organizations [36]. According to critical social theory, people are capable,and self-reflection and self-determination are basic needs that everyone has to act independently.Through emancipation [42] organizations can promote empowerment and allow a “critical mass of staff” to become a reflective organization, where staff define and solve practical and organizational issues at the work place [35, 41]. A critical mindset is crucial in developing areflective healthcare organization, and a political dimension is implicitly linked to a critical awareness where inherent ideologies are challenged. Our view is that both the individual psychological and social group critical perspectives of empowerment are relevant for understanding our results, and that the municipality organization did not seem to strive for an ethical climate where collective wisdom and knowledge was encouraged [36]. On a group level, the caring practice (both for staff and FLMs) needs legitimacy in order to define themselvesindependently (e.g., what issues they have and how to solve them). The psychological perspective highlights each person’s need to do things that are meaningful in order to feel satisfaction in their job. Employees who are expected to perform tasks without understanding
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why, in this case being part of a change that did not make sense, weakens them and may lead to anegative impact on work performance. Empowered employees, because they tend to have high intrinsic task motivation, exhibit increased concentration, effort, and resilience when performing tasks [43].
One result of our study showed that some of the FLMs lacked information and seemed to be even less involved in the process of change than the staff for whom they were responsible. We also found that participants questioned the purpose of the changes, and that it seemed unclear and possibly unnecessary to make these changes. This may have been due to the feeling, admitted both by staff and FLMs, that participants expressed humbleness toward one another. They were all in the same position of not knowing and having low influence. In a study by Dellve and Wikström [44], managers expressed that knowledge about motives (incentives) was needed for big decisions made by politicians together with continuous communication between higher decision makers and middle managers. In the same study, managers expressed that it was a challenge to improve staff participation in development work.
Participants in this study asked many questions about the projects. This is in line with the concept of a “critical awareness”, and according to Ghaye [35, 41] that is a prerequisite for building a reflective practice. Staff being critical and asking questions can be seen as a positive virtue from management, as this supports the building of a reflective organization. The reflective practice can be valuable because it enables teams to make improvements and develop the workplace from within [35]. Reflective practice emphasizes meaningful dialogue and the problematizing and questioning of the world. A critical disposition is an important brick in the building of a reflective healthcare organization. This can contribute to a workplace culture wherestaff becomes aware of working practices in need of improvement, and also takes action in orderto improve those practices. Steiner and Steiner [38] concluded that organizations ought to promote a culture in which everyone has an interest and maintains ownership of his or her own knowledge, learning, and development. The key is to discover how human and organizational assets can be balanced so that when combined, they create value for everyone in the organization, including staff and management [36].
In Sweden, the IT and the municipality healthcare sectors of the labor market are largely gender segregated and dominated by women [45, 46]. Hirdman [47] describes the gender system, whichis seen as feminine in general, as subordinated in the society as a whole. According to feminist thinking, subordination of women is inherent in societal and organizational structures [48]. In this study there were several statements that regarded a feeling of not being listened to and a particular emphasis that especially women are not listened to. In addition to the political aspect of changes in relation to increased use of ICT, and from a structural point of view, future research should use a gender perspective when introducing ICT in municipality healthcare. This would be especially pertinent in nursing and caring contexts, since these labor sectors are highly gender segregated into groups with low autonomy and status.
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5. Study limitations
It might be considered as a limitation that the question about management of the project was added after data collection had begun. Some of the participants might have added more views on management of the project if the aim had been formulated with that scope from the very beginning. Still, what motivates the authors’ decision of highlighting the management perspective is the fact that the participants initiated the subject in the interviews, because they viewed it as a significant issue.
Participants in this study sometimes expressed a general disappointment about the municipality management and brought up stories not only related to implementation of ICT during the interviews. The authors decided to not limit participants’ expressions or try to lead them back to the ongoing project; participants were negatively affected by their overall views of management in the organization and several ongoing and past changes. Therefore, we do not claim that this study’s results can only be related to the change process of the implementation of ICT. It isprobably and not only the case in this study that several changes took place at the same time, and therefore this study may contribute to some insight that more consideration to overall situations are needed, especially when external projects are established as change process models.
Another limitation is that the number of participants in this study, especially from the FLMs perspective, is small and that it would be fruitful to further investigate to what extent FLMs have influence or are involved in decision making when it comes to changing work procedures for staff at the wards (enrolled nurses and nurse aides). In the second municipality, five out of nine FLMs did not want to participate in the study, and potentially more effort could have been made to recruit other municipalities to obtain a broader perspective of the FLMs. The authors decided to not expand data collection to further municipalities, since it most likely would have been a time-consuming process to find municipalities going through similar changes at that specific time.
Interpretation was a conscious process; however, part of interpretation is an unconscious process and is intuitive. Any interpretation depends on and is limited by each researcher’s previous understanding and theoretical knowledge. The intention of this study was not to find “the truth”, as there are multiple constructions of how we interpret and view phenomenon and the world around us (Merriam, 2009).
6. Conclusions
In conclusion, our understanding is that responsibilities and management in the change process were unclear. This was problematic, because it created uncertainty among those involved. The ICT seemed to have some benefits, but these were somehow overshadowed by the unclear process. The staff was invited to participate at the beginning of the project without any real possibilities of influencing the process. This may have led to increased frustration among them,since they initially had expectations that later were shattered. Interestingly, the FLMs seemed to be even less involved in the changes than the staff. Empowerment as an ethical value in organizations can contribute to an overall shift in management by starting to build acceptance for a reflective healthcare organization. It is problematic that persons not working within the caring
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practice or those with an outsiders’ view, could define care as a staff issue. The implicit message then becomes that care work is not attractive, and we need men and technology to change this. That mindset is the opposite of everything for which empowerment stands.
Future research should focus on how to work with changing management toward a reflective practice built on the value of empowerment. An action research approach in collaboration with the municipality organization might be fruitful for further research. Furthermore, communication plans could be used to better give and receive information and feedback for the ongoing process.This study showed a lack of clear management, and, therefore, the role of the FLM in elderly care also needs to be strengthened and clarified.
Acknowledgements
The authors would like to thank all participants of this study for their commitment and time that made this study possible.
Conflict of interests
There are no conflicts of interests.
Ethical approval
The staff was informed about the study in both written and verbal forms. They were informed that participation in the study was voluntary and that they could drop out at any time without explanation. The Regional Ethical Review Board in Umeå, Sweden approved the project (Dnr 09-209M, 2009-1414-31).
18
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[30] McConnell C.R. Change can work for you or against you. Health Care Manag 2010; 29 (4):365-374.
[31] Charmaz, K. Gathering rich data. In: Charmaz, K. Constructing grounded theory. A practical guide through qualitative analysis. London: SAGE Publications: 2006; p. 13-41
[32] Kvale, S. Interviews. An introduction to qualitative research interviewing. Thousand Oaks: SAGE Publications: 1996; p. 81-103
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[33] Merriam, S. What is qualitative research? In: Merriam, S. Qualitative research. A guide to design and implementation. San Francisco: Jossey-Bass; 2009; p. 3-19.
[34] Alvesson M, Sköldberg K. Tillämpning av reflexive metodologi [Application of the reflexive methodology]. In: Tolkning och reflection [Interpretation and reflection]. Studentlitteratur: Lund; 2008; p. 503-528.
[35] Jansson M. Participation, knowledge and experiences. Design of IT-systems in e-home health care [dissertation]. Department of business of administration and social sciences. Luleå University of Technology 2007.
[36] Bergum V, Dossetor J. Relational ethics. The full meaning of respect. Maryland, University Publishing Group Hagerstown; 2005.
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Paper IV
1
Technologies in elderly care - values in relation to a caring rationality
Andersson Marchesoni Mariaa, Axelsson Karina, Fältholm Ylvab & Lindberg Ingera
aDepartment of Health Science
Luleå University of Technology,
SE 971 87 Luleå, Sweden
bDepartment of Work Science
Luleå University of Technology,
SE 971 87 Luleå, Sweden
Maria Andersson Marchesoni, RN, MSc, PhD student
Karin Axelsson, RNT, Dr Med Sc, Professor Emerita
Ylva Fältholm, PhD, Professor
Inger Lindberg, RNM, PhD, Associate Professor
Correspondence to:
Maria Andersson Marchesoni
E-mail address: [email protected]
Tel: +46 920493873
Division of Nursing,
Department of Health Science, Luleå University of Technology,
SE 971 87 Luleå, Sweden
2
Abstract
Background: The tension between care-based and technology-based rationalities
motivates studies concerning how technology can be used in the care sector to
support the relational foundation of care.
Objectives: This study interprets values related to care and technologies connected to
the practice of good care.
Research design: This research study was part of a development project aimed at
developing innovative work practices through information and communication
technology.
Participants and research context: All staff (n=18) working at two wards in an
elderly care facility were asked to participate in interviews and 12 accepted. We
analysed the data using latent content analysis in combination with normative
analysis.
Ethical considerations: The caregivers were informed that participation was
voluntary and that they could drop out at any time without providing any explanation.
Findings: Four values were identified: “Presence”, “Appreciation”, “Competence”,
and “Trust”. Caregivers wanted to focus on care-receivers as unique persons, a view
that they thought was compromised by time-consuming and beeping electronic
devices. Appraising from next-of-kin and been seen as someone who can contribute
together with knowledge to handle different situations were other desires. The
3
caregivers also desired positive feedback from next-of-kin, as they wanted to be seen
as professionals who have the knowledge and skills to handle difficult situations. In
addition, the caregivers wanted their employer to trust them and they wanted to work
in a calm environment.
Discussion: Caregivers’ desire for disturbance-free interactions, being valued for
their skills, and working in a trustful working environment were interpreted as their
base for providing good care. The caregivers’ arguments are based on caring
rationality and sometimes they felt the technological rationality interfered with their
main mission, providing quality care.
Conclusion: Introducing new technology in caring should support the caring
relationship. Although society’s overall technology-based approach may have gained
popularity as a problem solver, technology-based rationality may compromise a care-
based rationality. A shift in attitudes towards care as a concept on all societal levels is
needed.
Keywords
Caring, normative analysis, elderly care staff, technologies, Tronto’s feminist care
ethics, values
4
Background
The majority of individuals in primary care and living in elderly care facilities in
Sweden have severe diagnoses.1 The way we view mortality has changed as we live
longer, resulting in very complex care needs.2 Providing care for such people
involves both meeting physical and/or cognitive needs and being sensitive to daily
changes.3 Caring for older people involves many components and should not be
idealized or romanticized. The workload in elderly care settings is heavy, routine, and
physical.4 Care is more likely to be filled with inner contradictions, conflicts, and
frustration than it is to resemble idealized interactions between a nurse and a
patient/client.5 The care-based rationality demands mutuality and flexibility to
accommodate the shifting needs of care receivers3, a process that often is invisible
and immeasurable, where caregivers sometimes take time to provide unquantifiable
emotional support to care receivers.6 Care rationality is based on values such as
interdependency, mutuality, relationship, integrity, patience, and respectfulness.
Relational and feminist ethicists claim that the majority of dilemmas in healthcare
and social care occur during day-to-day activities and are not dramatic situations.
Even so, the dilemmas are of great importance for the wellbeing of those involved.7,8
Working in elderly care is considered a low-status profession in Sweden. This low
status is connected to cultural values; in Sweden, as in similar Western societies,
productivity and youth are highly valued and elderly persons are seen as an economic
burden on society.9 Elder care has also been described as the least popular and
5
attractive area as a career option for nursing students10 and as boring, unproductive,
and inflexible.11
Information and communication technology (ICT) has been proposed as a means to
meet the needs of an increasingly aging population with great caring needs and fewer
resources for providing care.12,13,14 The growing emphasis on ICT solutions based on
a technical rationality raises the question how technology can be integrated and used
in the elderly care sector as a means to support relational care.15 ICT is also a way to
attract young persons to work in municipality elderly care.12,16 Business- and market-
based values,17 where ICT is seen as a means to become more efficient, are in line
with a technical rationality. Technical rationality18 aims to structure and systematize
the work of caregivers and concepts like effectiveness and structuring are related and
can be linked to economy and power.19 Caring rationality and technical rationality
can be linked to femininity and masculinity in a highly segregated labour market.20 In
Sweden, the labour sectors for ICT and government-based healthcare for the elderly
are to a large extent gender segregated.21,22,23
Feminist research states that all research is political; it always strives towards
changing something.24 Tronto5 (1993, p. 157) concludes that “care is a central but
devalued aspect of human life” and that we need to understand care as a political idea
to change its status and the status of those who do care work. Tronto bases her
feminist care ethics theory5 on four elements of care: attentiveness, responsibility,
competence, and responsiveness. Attentiveness means that someone is being attentive
6
to another person’s needs of care and takes responsibility to respond to care needs. To
perform care requires competence, which is the moral dimension of an ethics of care,
and without responsiveness no care can be performed. The four elements have strong
connections to each other. In a context of constant change, where health professionals
have to make sense of policy, practice, political, and professional imperatives, there
is little time to reflect on the value of care. To reflect on the value of care (i.e., caring
cultures), a slow practice and slow ethics are suggested.25 A slow practice means that
activities that are complex and often charged with emotion should be approached
with care and attention Slow ethics can be briefly described as taking the time to
reflect on the meaning and value of care. Healthcare practice is based on a
meaningful engagement with a focus on the quality of healthcare interactions, the
ethical climate of organizations, and the experiences of patients, family, and
healthcare staff.25
Values can be identified in everyday life indirectly from a person’s verbal or non-
verbal expressions. Values of positive importance are organized in a system that has
meaning to a particular individual.26 As values help reveal what people desire, they
can have motivational power; they serve to justify personal opinions and actions.27
Values can be divided into hierarchies of intrinsic and extrinsic values. Intrinsic
values are good per se, since they are independent and favourable in and of
themselves regardless of external factors. Extrinsic values are relative to something
7
else that is perceived as being good or desirable. A criterion for distinguishing a value
from a personal opinion is that a value has an inter-subjective validity.28
Hedström29 studied values and ICT in elderly care settings and identified four main
values: administrative values, integration values, care values, and professional values.
These four values encompass a variety of other aspects, including cost reductions,
mutual perspectives on work routines, increased time for the elderly, and increased
status of the work. Nurse assistants and enrolled nurses saw economic, working
environment, and utility as ways to evaluate whether to accept or reject ICT
solutions.30 Technologies are always value laden due to their function and purpose31
and additional considerations to evaluate the beneficial outcomes of welfare
technologies are needed since only a few technologies can actually document such
outcomes.32 Assessing the outcome of technologies in healthcare is always a question
about who benefits from such technologies, as many stakeholders are involved who
are influenced by market and economic forces.33
Care is a relational and a societal matter. Care has an intrinsic value that is
unquestionable: everyone needs care, but care work is devalued in society. The
emphasis on a technology-based rationality in care work to make the practice more
efficient might have a negative impact on the care-based rationality. The question is
this: Has emphasis on technical rationality gone too far by undermining the need for
status enhancement that relational and body intensive work (such as elderly care)
should actually have? As discussed above, policy makers emphasise that ICT is a
8
support mechanism for healthcare, but there is a gap when it comes to studies that
highlight the relational foundation of care when introducing ICT. Questions remain
as to what values technologies should support to be beneficial in elderly care and how
such technologies can support the relationship between the caregiver and the care
receiver. In light of these questions, our aim is to interpret values related to care and
technologies connected to the practice of good care.
Methods
Design
This qualitative descriptive and interpretive study uses latent content analysis
inspired by Woods and Catanzaro34 and normative analysis to interpret values. In a
normative approach, it is possible to study how something ought to be in contrast to
how something actually is.35 The normative analyses in this study focused on
highlighting the values and arguments used by the participants. These arguments are
a way of claiming the good or bad aspects about something before rationalising a
standpoint for or against a claim.
The FIA project
This study was connected to a research and development (R&D) project aimed at
developing innovative work practices (the FIA project). For this study, the part of the
FIA project involved two elderly care facilities in one municipality in Sweden.
Caregivers were invited to participate in workshops led by a project leader with a
9
technical degree working in the ICT sector. The workshops were conducted with the
aim of determining areas where digital solutions could provide future improvements
in healthcare and social care. The first author of this study attended the workshops. In
addition, the first author also attended information meetings and educational courses
during the project. Informal conversations with caregivers were frequent throughout
the entirety of the project.
The digital solution developed during the project was a personal digital tool (a
smartphone) aimed at providing safe and individualized handling of prescribed
medications for each person living in an elderly care facility. The caregivers used the
digital tool with the intent that the tool would eventually replace pen and paper.
Increased accuracy and efficiency in dispensing medications were believed to be a
positive outcome of using the tool. A second belief was that using technology could
improve the status of caregivers in society.
Participants and data collection
All enrolled nurses and nurse assistants (n=18) who had attended meetings in the
FIA project were invited to participate in this study; 12 individuals accepted (Table
1). The interviews took place in a quiet room outside the wards but within the
building of each person’s workplace. Before each interview, 10–15 minutes were
dedicated to providing information about the study to the participant.
10
Table 1. Participant characteristics.
Total number of persons asked to
participate (males/females)
18 (2/16)
Participating males/females 2/10
Participants’ age range 25–60
Years of working experience, range 5–30
A mind-map was used as interview guide and included three areas: “technology,”
“gender”, and “care practice”. Since interactions between the first author and
participants were on-going, the interviews started with questions of a follow-up
nature (e.g., “How is the development in the project and the technology going?”).
Interviews proceeded to focus on descriptions of technology and care practice.
Questions such as the following were asked: “How does technology (in general but
also the specific solution in the R&D project) change your work?”; “Does the
technology ease or hinder you in your work?”; and “Is the relationship towards the
care receiver affected by technology?”.
Questions about care practice included “What is challenging in care practice?” and
“What education or traits are important in this work?”. More open questions were
used, such as “Tell me what caring is for you”. On average, the interviews lasted 80
minutes and the first author conducted and transcribed all the interviews.
11
Analysis
All interviews were read with a focus on caregivers’ expressions and how they gave
voice to their view of their work in relation to care and technologies. Expressions
about care and technologies were sorted out and divided into text units. Each text unit
was assigned an identification code to facilitate the process of going back and forth
during the analysis. These text units were then re-read with the intent of clustering
and condensing the text.
The next step was to read the clustered text units with a focus on interpreting what
value the caregiver was advocating. This process was facilitated by posing two
questions while reading the texts: “What are they arguing for and what do they
desire?” and “What are they striving towards and what is considered good or
desirable?”.35 All authors independently read parts of the data and independently
identified values; the individual interpretations were compared and discussed. The
grouped and condensed text units were formulated as arguments supporting each
value.
Ethical considerations
The caregivers were informed about the study in written and oral form. They were
informed that participation in the study was voluntary and that they could drop out at
any time without providing any explanation. The Regional Ethical Review Board in
Umeå, Sweden approved the project (Dnr 09-209M, 2009-1414-31). Furthermore, the
12
researcher’s role in the FIA project was emphasised at every project meeting with
caregivers attended by different representatives from the project.
Results
Our analysis resulted in four interpreted values (Table 2). The staff used different
arguments for how good care could be obtained and these arguments were used for
the interpretations of each value.
Table 2. Interpreted values and arguments relating to each value.
Interpreted value Arguments
Presence Focusing on the person behind the illness
Making the care receiver content and satisfied
Interacting with the care receiver without disturbance
Time-releasing technology
Appreciation Getting approval and appreciation from next-of-kin
Being listened to
Being seen as someone who can contribute
Competence Knowing what and how to document
Being emphatic and skilled in non-verbal language
Having knowledge in diseases and managing symptoms
Trust Working without feeling stressed
Being able to trust their employer
Working in a calm environment
Evaluating critically
13
Presence
Expressions of wanting to focus on the person behind the illness and making them
content and satisfied have been interpreted as relating to the value of presence.
Meaning in one’s work was interpreted as being able to see the person behind the
illness (persons with dementia were often mentioned) and being able to meet that
person as a unique person, not being distant and governed by routines or beeping
electronic devices. The value was interpreted as a wish to be both mentally and
physically attentive to the care receiver. This value raises internal conflicts between
taking care of elderly by being present and attending the requirements of the
technologies. For any technology to gain acceptance from caregivers, it has to
facilitate the possibility of being mentally focused on the care receiver. In other
words, technology has to ensure that staff can still remain attentive to the care
receiver.
To be totally honest, I must say that it feels much better to go to the
care receiver than messing around with these technology
applications. We are here to take care of them [the care receiver]
and not to take care of the technologies and they are living persons
and these applications we are using are not living creatures; even if
they would work well and function, they don’t. And I don’t know,
even if all the technologies would work fine, they would be of no use
for me. I think the intention is good but I don’t know what to say. It
must not become too mechanised, everything in care. (Caregiver 1)
14
When caregivers are able to have an interaction that brings joy and happiness to the
care receiver, they feel good about their work and themselves, especially if they
receive positive feedback. However, these moments of joy were often discussed in
relation to a dilemma involving external demands to systematise and structure tasks,
some of them related to ICT systems. This dilemma reduced the possibility of being
focused and present on tasks that gave caregivers positive feedback from the care
receiver.
Being capable of changing one’s own manners and being open and focused when
going from one room to another in the wards were examples of the challenge of what
being present meant in practice. It was regarded as essential for caregivers to be alert
and present in their mind-set to meet each person irrespective of that person’s
individual and changing moods and habits. To have interactions with the care
receiver without being disturbed was interpreted as already being difficult to achieve,
and the new ICT systems increased the feeling that interacting without being
disturbed was difficult.
For one of our care receivers you cannot drop focus from her because then she
stands up and starts to go away . . . for example, in the morning when she
showers, I have to prepare and take everything into the shower-room because if
I turn around from her for just a moment, she is on her way. It is the same if I
am standing and using that mobile phone. It does not work because I lose focus
on her, so I don’t use it when I am at her place. I prioritize the care receiver.
(Caregiver 2)
15
Using one’s hands (e.g., the physical dimension of the work) was interpreted as
essential as these were working tasks where receiving positive feedback could be an
outcome. Technologies that allowed the caregiver to remain present and focused on
the care receiver were ascribed a positive value, because they allowed the caregivers
to interact with the care receiver without being disturbed. Technologies of this kind
were seen as facilitators and a normal procedure in the physical part of the work.
These technical aids were not even conceptualized as technologies but rather as
“assisting aids”. Several caregivers gave examples of technologies they believed
would save time (e.g., robot vacuum cleaners), allowing increased interactions with
care receivers. No one questioned the use of wheelchairs, safety or alarm systems,
hearing aids, or monitoring medical parameters (such as blood sugar and blood
pressure). On the contrary, technologies that made it difficult to be present were the
ones that made caregivers feel frustrated.
Being present is also related to taking responsibility for documentation, a task that
caregivers approached differently. These differences created some conflicts between
caregivers. There was some irritation over different ways of dealing with the
technologies. Some caregivers did not want to document using the electronic
documentation system and instead let others perform their documentation tasks.
16
Appreciation
Arguments relating to technologies and being appreciated arose when caregivers
discussed a kind of technology that they used on a daily basis and how such
technologies could affect interactions with next-of-kin. Electronic documentation,
one of those technologies, was described as something that made it possible for staff
to show both the next-of-kin of the care receivers and medical staff superiors that
they had done what they were supposed to do. Therefore, the use of electronic
documentation can also be interpreted as wanting to show responsibility and wanting
to be appreciated as such.
Ensuring good communication and being seen as responsible by next-of-kin was an
important value for caregivers. Caregivers used conversations with next-of-kin,
especially any signs of approval or disapproval, to interpret how the care they
provided was perceived by the next-of-kin. For example, when caregivers reported
feeling disapproval from next-of-kin, it was clear that these feelings had a negative
effect on caregivers. In some cases, the electronic documentation system was
beneficial for staff since the use of such as system could confirm, in the case of
disapproval among next-of-kin, that care actions were performed in accordance with
issues relevant to the care receiver. These incidents were somehow taken as an
indication of whether one was doing a good or bad job.
I was used to do it [social record documentation] because it was the
only way to communicate with my colleagues, so it was important and
17
we are doing it here too. But we do it electronically and I have no
problems with that, but some of my colleagues do. The thing is that if
we don’t document well, it is like nothing has happened. We cannot
just say, well, she didn’t want to go out today, or she did not take a
shower today. We have to write it down also. There is no use even if
everyone working at the ward stands in line all together saying the
same thing, because no one believes us. If it is documented, there will
be no discussions. (Caregiver 4)
Concerns about wanting to be viewed as someone who can contribute was described
in relation to the on-going R&D project. This project seemed to lead to an overall
feeling among caregivers of not been appreciated since they were not asked to really
contribute to the process.
Caregivers described a feeling of not being appreciated for their previous actions and
how seldom they felt that someone in a management position listened to their
opinions. Furthermore, caregivers remarked that it was rare that they were considered
to be someone who was able to contribute in organizational development and
projects. They expressed a desire to be seen as people who could contribute rather
than being considered ignorant because of their position “at the bottom” of the
organization. Participants seemed to be resigned and were rather harsh when they
talked about these issues.
To be appreciated and valued mainly involved caregivers’ awareness of the
importance of being able to balance the needs and expectations of care receivers,
next-of-kin, the organization, and society as well as being affirmed as capable of
18
accomplishing what was expected of them. Wanting to be seen and appreciated also
involved an awareness of the multiple aspects of working in a public care
organization with several competing lines of interest. This complexity can be
interpreted as issues that cannot be targeted by any technology. As a result, it is
necessary to raise questions that perhaps both human and economic resources are
being used for the wrong causes. Caregivers asked for more appreciation from
different people involved in different aspects of their work. At a societal level,
increased and frequent negative media publicity was described as having a huge
negative impact on caregivers. The desire to be confirmed as a caregiver was fulfilled
when the caregiver was with the person in need of care and receiving a response to
the care being provided. Being confirmed as a caregiver with a smile or even a hug
from the care receiver was part of caregivers’ positive descriptions of their work.
Many times the positive feedback comes from our care receivers, those who can
and are lively; then we have those [who are the] opposite, but this [attitude]
often [comes from] demented persons. But you can wish that you can get more
positive feedback from our employer than what we get. (Caregiver 12)
Competence
Many of the caregivers talked about lack of competence in a variety of areas, such as
secure documentation, disease management, palliative care, empathy, and sensitivity
towards non-verbal language. Many of the caregivers also noted that the prevalence
of psychiatric diseases was increasing and that they lacked knowledge in how to deal
with care receivers with different psychiatric symptoms.
19
It is important to be capable in one’s work and have the right qualities
and qualifications, and that includes many things like seeing when
someone is having a medical issue, knowing how to prioritize, and
having the knowledge to know about what causes different situations.
But it also has to do with being good in interacting with a variety of
people. It is very important to be good in approaching different
people, to be professional. When I’m helping someone with matters
that are physically intimate, for instance, I must think of every step I
take, about how I’m approaching the situation, to do a good job. I
always have to strive towards doing it as well as possible and not
violate the person. It has to be done in the gentlest way that is
possible. And these kinds of skills have to be practiced so that it
becomes part of you in your work. (Caregiver 5)
The employer’s emphasis on newly implemented ICT and the importance of
documenting in an accurate way made caregivers question their own capabilities.
Caregivers were well aware of the importance of maintaining social record
documentation and of the need to be present when performing these tasks, but it
seemed as if the electronic documentation required more reflection on what and how
to document. In other words, being competent involves being aware of the value of
social record documentation and having the skills to perform the task well. Writing in
a certain manner and having the time to reflect properly on the situation were
considered important but impossible prerequisites. Caregivers feared being reported
to an authority and possessed a high degree of awareness of the importance of
documenting all events (e.g., falls, anxiety, sleeping problems, and pain). These fears
20
were related to being focused on the ICT. All caregivers were aware of the fact that
documentation was not optional. Caregivers explained how difficult the social
records documentation was compared to writing down medical parameters such as
blood sugar levels or body temperature. Composing the social record documentation
involved a high degree of interpretation; what is recorded is more likely to vary
depending on each caregiver’s interpretation of the care receiver’s situation.
Furthermore, all documentation also was done electronically and for some caregivers
this situation was an aggravating circumstance.
I was trying to login [smartphone for medication administration] in
the room in which a person that was in terminal care lived and I held
this thing in my hand and it wasn’t working so I had to put it down,
and then I talked with the day staff and we came to the conclusion
that it doesn’t feel or look good to be focused on an electronic
gadget in a situation like that. (Caregiver 8)
Managing different symptoms involved knowing when a situation was solvable by
the caregiver and when to consult a registered nurse (RN). Being empathetic and
sensitive to non-verbal language was described as being important when caring for
persons with dementia because the ability of care receivers to communicate verbally
decreases as the disease progress. Caregivers were aware of an imbalance of power
between themselves and care receivers and were aware that care receivers sometimes
held back feelings of sorrow when moving into elderly care facilities. Caregivers
knew they had to be even more attentive to non-verbal language during interactions
with care receivers who were moving into such facilities.
21
Trust
We identified trust as one important value for caregivers; mistrust made caregivers
feel insecure and stressed. These discussions came to light in relation to employers’
and project leaders’ explanations of the usefulness of ICT innovations. To have trust
meant to see a meaning with any change and in this case changes that involved ICT.
Staff has to be listened to, but now we are not trusted; sometimes it
feels as we are second order people so to say and that disturbs me
very much because I think our knowledge and qualification . . .
should be taken advantage of, not as they do today. I believe that the
employer makes a terrible mistake regarding us staff, they do not take
advantage of what is available but instead always look for anything
new, but I think they should be very surprised if they could see us
because, of course, there is new and good [technology] available, but
the experience we have you must have been around a while to get.
(Caregiver 4)
Several caregivers had many years of work experience and they remembered “the
good old times” and longed to work in that manner again. This longing also involved
a wish to work in a calm environment where caregivers felt they could trust their
employer when it came to working towards broader goals. When caregivers described
the importance of working in an organization where they trusted their employer, they
expressed an internal feeling. Caregivers mostly used the words “calm” and
“tranquillity” to describe what they strived towards and what they wanted to feel for
the employer. To work in a calm environment was described as a prerequisite for
22
staying focused on whatever task occupied one in a given moment. For example,
caregivers expressed a desire to not feel stressed when they were assisting a care
receiver to take a shower or using a computer to document results. Our interpretation
was that caregivers already worked under strained conditions, and many of their
emotions during the interviews were a result of already having more than enough
stress to deal with.
Caregivers talked about the aims and usefulness of ICT and were critical about their
organizations. Caregivers believed that they exhibited responsibility by questioning
their employers’ vision and adhering to ideal and ethical standards by focusing on the
care receiver in their work. Thus, the ideals of the organization became a target of the
caregivers’ frustration. A shared vision and a common goal to give good care became
murky and seemed to affect caregivers at a deeper level by creating feelings of
mistrust towards their employers.
Several statements made by caregivers revealed mistrust towards employer and
involved the employer presenting a nice façade and promising a lot to next-of-kin,
but being unable to deliver on his or her promises. ICT systems were related to a
sense of mistrust, as they were seen as something that could prove that caregivers
were acting incorrectly, especially in challenging situations. Trust also involved a
demand on the employer to make critical evaluations before introducing or even
testing new work procedures that involved the implementation of ICT. Caregivers
complained about inconsistencies and that changing work procedures sometimes
23
seemed to be related to what was on the agenda at the moment. The agenda did not
necessarily have to do with the perceived overall needs of care receivers living in an
elderly care facility but rather with satisfying some issue highlighted externally.
Caregivers wanted to work in an organization that scrutinized any change before
implementing it.
It must be practical to use, all technologies we have here. This is a
practical work. It also needs to be resistant to water and not break
into pieces if we drop it on the floor. Technologies could help us in
many ways but no one really cares to see what help we need.
(Caregiver 5)
Discussion
Caregivers in our study emphasized that they wanted to be present and interact with
care receivers without disturbance, a prerequisite for ensuring the contentment and
satisfaction of the care receivers. This interaction seemed to be important source of
meaning in caregivers’ work, since caregivers expressed a lack of being appreciated
by their employers, the care receivers’ next-of-kin, and society. The caregivers’ wish
of being present and having disturbance-free interactions can be understood in
relation to the concept of attentiveness5 and has likewise been described in a study36
where RNs in elderly care valued caring time instead of administrative tasks.
Caregivers in our study wanted to see the person behind the illness and be attentive
towards not only the person’s medical conditions but also their personal preferences
and shifting needs. Being attentive, according to Tronto, requires listening to
24
articulated needs, recognizing unspoken needs, distinguishing among needs, and
deciding which needs to attend.5 Staff were also attentive to their own needs of
working under certain conditions; they exhibited a critical awareness of sometimes
being unable to meet the needs of care receivers. Being aware is a prerequisite for
good care, still it can create a dilemma when the caregiver at the same time has a
reflective predisposition and can determine that many needs remain unmet.
The smartphone used in this particular project was a source of stress for the staff,
particularly when it was not functioning or when it disturbed a situation and made it
hard for caregivers to be attentive and present. As a result, the attention of caregivers
was divided. Since they were keen to explain their already strained situation, both
before and during the on-going development project, our understanding is that
caregivers somehow tried to justify why the project added frustration to their
everyday work.
Our study has revealed that caregivers want to be seen, appreciated, and approved as
people who are able to contribute in organizational changes and projects.
Furthermore, staff in our study clearly stated that they felt that their working
environment was deteriorating and they did not trust their employer. In addition,
caregivers did not feel trusted since electronic documentation somehow was a way of
proving that they did their job and what was expected of them, turning the technology
into a device their employer could use to monitor their work. Caregivers also felt that
employers did not take enough responsibility for critically evaluating a situation
25
before starting a development project. Shared understandings and values are the
foundation for building trust. Trust between persons working in healthcare –
caregivers, administrators, and policy makers – is the basis for moral relationships;
morality is a part of human life.37 Trust is built on moral relationships and such
relationships are sustained by some shared standards that will lead to human
flourishing, trusting that others will stand by and adhere to these standards. Our
results are in part descriptions of mistrust, both from staff towards their surrounding
structures and from the surrounding structures towards staff. The staffs needs to trust
that their superiors implement policies that serve the needs of the care receivers as
well as the staff and their superiors need to trust staff to act as professionals. This
trust can only be developed if both parties contribute to the planning and
development of any new projects.
Feminist theorist recognize that caring relationships are built only when both
caregivers’ and care receivers’ needs are met.5,38 A moral relationship, where mutual
expectations prompt humans to call on each other, necessitates a response; repeatedly
unmet expectations or calls for attention can result in mistrust.37 In our study,
expectations from staff were not only directed towards the employer but also the
expectations that caregivers had for themselves. Caregivers were attentive towards
the needs of care receivers, yet they sometimes failed to meet these needs. As we
understand the caregivers, they needed calm and trusting environment, a sense of
being present and feelings of appreciation and competence in order to be able to do a
26
good job and provide good care. Technology should support these values and not
cause stress or shift attention from the care receiver to the technical application.
Staff did stress that the relational aspect of having competence involved being and
remaining empathetic and being skilled in non-verbal language communication,
whereas the medical competence per se involved knowledge of a variety of diseases
and how to identify and manage symptoms. According to Tronto, competence is a
moral dimension of caring as it means to assume and to take seriously the
responsibility of action.5 Caregiving requires that individuals and organizations
perform the necessary caring tasks with accurate competence. Incompetent care is not
only a technical problem but also a moral one.5 Competent care assumes the
responsibility to meet a need that has been identified. Simply seeing a need (being
attentive) for care is not enough to make care happen. If a technical application fails,
it could reflect a lack of competence in the entire organization.
Overall, the results of our study somehow provide a picture of unmet expectations,
and certainly there are multiple ways of understanding what happens when
expectations are not met. Nevertheless, an emotional response to failure with anger,
frustration, and/or guilt can be interpreted as moral distress.39,40,41 The overall
expressions of caregivers are those of mistrust; the way in which unmet expectations
were addressed indicates moral distress. Moral distress can lead to feelings of
anxiety, powerlessness, and ineffectiveness, and feeling that one’s personal beliefs or
values are being violated; a sense of failed responsibility may also develop.39
27
However, the technologies that facilitate communication and support on-going
relationships were accepted by caregivers. At times, these technologies were not even
described as technologies. Before implementing a technology, it would be wise to
thoughtfully and reflectively examine which goal of care the implementation hopes to
support. By using a critical lens and on-going dialogues about the goals of care, the
choice of using technology to achieve those aims can be made more purposefully and
changes that are not viable can be dismissed from the start.33
Methodological considerations
In this study, we used a normative approach to interpret values. Values are closely
connected to ideals about how something ought to be and therefore, of course, do not
always resemble what the reality is. Thus, the reality differs when it comes to
understanding how people interpret phenomena. Therefore, it is essential to note that
the results in this study relate to ideals from caregivers in a specific context (elderly
care in Scandinavia). According to Badersten,28,35 it is important that the assumptions
about the analysis are clearly stated. Identifying values is not a straightforward
process and no model can provide a fool-proof formula for arriving at a common
identification. Accordingly, we emphasised that care is relational. To gain
trustworthiness and promote a reflective interpretation, all authors were active in
identifying values, and the individual interpretations were compared and discussed.
The way in which normative analysis is used in political science certainly does not
resemble the way in which we used normative analysis in this study. We by no means
28
claim to have conducted our analysis according to that standard. However, our
approach of looking at empirical data with the idea of not just describing what was
said but also analysing what caregivers are striving towards and what they desired in
terms of care and technologies was fruitful. The four values that we identified are
based on statements made during the interviews with the caregivers. These values are
interpreted to be important for caregivers, but as the method implies, values are not
fixed; values are normative constructions assembled by human beings. In other
words, those values do not need to be followed or obtained to the fullest extent, but
they still are worth striving towards as a means to practice good care.
Conclusion
Although this study was conducted in a Swedish context, we still maintain that the
emphasis on a technological rationality has gained a worldwide acceptance and
therefore the results of our study can be applied in other cultural contexts. With
reference to the tension between technology and caring, our overall understanding is
that technologies have gained popularity as a problem solver, a view that may lead to
less focus and fewer resources allocated to discussions based on caring rationalities.
A shift in attitudes towards care on all societal levels is needed. Technologies in
relation to values (i.e., how technologies can be a means to support good care and
how these technologies can be put into practice) should be placed at the centre of
discussions about care among policymakers, managers, staff, and the public.
29
Funding
The study was supported by the Centre for Distance-spanning Healthcare CDH and
later eHealth Innovation Centre, EIC, Department of Health Science and Department
of Work Science Luleå University of Technology.
Acknowledgements
The authors would like to thank the participants for taking their time for the
interviews and sharing their thoughts and views about technology and caring.
Conflicts of interest
No to declare
30
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DISSERTATIONS FROM THE DEPARTMENT OF HEALTH SCIENCE, LULEÅ
UNIVERSITY OF TECHNOLOGY, SWEDEN
Doctoral theses
Terttu Häggström. Life-story perspective on caring within cultural contexts: experiences of severe illness and of caring. (Nursing) 2004.
Inger Jacobson. Injuries among female football players. (Physiotherapy) 2006.
Karl Elling Ellingsen. Lovregulert tvang og refleksiv praksis. (Health Science and Human Services) 2006.
Annika Näslund. Dynamic ankle-foot orthoses in children with spastic diplegia: interview and experimental studies. (Physiotherapy) 2007.
Inger Lindberg. Postpartum care in transition: parents’ and midwives’ expectations and experience of postpartum care including the use of videoconferencing. (Nursing) 2007.
Åsa Widman. Det är så mycket som kan spela in – en studie av vägar till, genom och från sjukskrivning baserad på intervjuer med långtidssjukskrivna. (Health Science and Human Services) 2007.
Eija Jumisko. Striving to become familiar with life with traumatic brain injury: experiences of people with traumatic brain injury and their close relatives. (Nursing) 2007.
Gunilla Isaksson. Det sociala nätverkets betydelse för delaktighet i dagliga aktiviteter: erfarenheter från kvinnor med ryggmärgsskada och deras män. (Health Science and Human Services) 2007.
Nina Lindelöf. Effects and experiences of high-intensity functional exercise programmes among older people with physical or cognitive impairment. (Physiotherapy) 2008.
Åsa Engström. A wish to be near: experiences of close relatives within intensive care from the perspective of close relatives, formerly critically ill people and critical care nurses. (Nursing) 2008.
Catrine Kostenius. Giving voice and space to children in health promotion. (Health Science and Human Services) 2008.
Anita Melander Wikman. Ageing well: mobile ICT as a tool for empowerment of elderly people in home health care and rehabilitation. (Physiotherapy) 2008.
Sedigheh Iranmanesh. Caring for dying and meeting death: the views of Iranian and Swedish nurses and student nurses. (Nursing) 2009.
Birgitta Lindberg. When the baby is premature. Experiences of parenthood and getting support via videoconferencing. (Nursing) 2009.
Malin Olsson. Meaning of women’s experiences of living with multiple sclerosis. (Nursing) 2010.
84
Lars Jacobsson. Long-term outcome after traumatic brain injury. Studies of individuals from northern Sweden. (Health Science) 2010.
Irene Wikman. Fall, perceived fall risk and activity curtailment among older people receiving home-help services. (Physiotherapy) 2011.
Christina Harrefors. God vård och användning av digitala hjälpmedel. Föreställningar hos äldre och vårdpersonal. (Nursing) 2011.
Agneta Larsson. Identifying, describing and promoting health and work ability in a workplace context. (Physiotherapy) 2011.
Lisbeth Eriksson. Telerehabilitation: Physiotherapy at a distance at home. (Physiotherapy) 2011.
Amjad Alhalaweh. Pharmaceutical Cocrystals: Formation mechanisms, solubility behaviour and solid-state properties. (Health Science) 2012.
Katarina Mikaelsson. Fysisk aktivitet, inaktivitet och kapacitet hos gymnasieungdomar. (Physiotherapy) 2012.
Carina Nilsson. Information and communication technology as a tool for support in home care. -Experiences of middle-aged people with serious chronic illness and district nurses. (Nursing) 2012.
Britt-Marie Wällivaara. Contemporary home-based care: encounters, relationships and the use of distance-spanning technology. (Nursing) 2012.
Stina Rutberg. Striving for control and acceptance to feel well. Experiences of living with migraine and attending physical therapy. (Physiotherapy) 2013.
Päivi Juuso. Meanings of women's experiences of living with fibromyalgia. (Nursing) 2013.
Anneli Nyman. Togetherness in Everyday Occupations. How Participation in On-Going Life with Others Enables Change. (Occupational therapy) 2013.
Caroline Stridsman. Living with chronic obstructive pulmonary disease with focus on fatigue, health and well-being. (Nursing) 2013.
Ann-Sofie Forslund. A Second Chance at Life: A Study About People Suffering Out-Of- Hospital Cardiac Arrest. (Nursing) 2014.
Birgitta Nordström. Experiences of standing in standing devices: voices from adults, children and their parents. (Physiotherapy) 2014.
Malin Mattsson. Patients’ experiences and patient-reported outcome measures in systemic lupus erythematosus and systemic sclerosis. (Physiotherapy) 2014.
Eva Lindgren. “It’s all about survival”: Young adults’ transitions within psychiatric care from the perspective of young adults, relatives, and professionals. (Nursing) 2014.
Annette Johansson. Implementation of Videoconsultation to Increase Accessibility to Care and Specialist Care in Rural Areas: - Residents, patients and healthcare personnel´s views. (Nursing) 2015.
85
Licentiate theses
Marja Öhman. Living with serious chronic illness from the perspective ofpeople with serious chronic illness, close relatives and district nurses. (Nursing) 2003.
Kerstin Nyström. Experiences of parenthood and parental support during the child's first year. (Nursing) 2004.
Eija Jumisko. Being forced to live a different everyday life: the experiences of people with traumatic brain injury and those of their close relatives. (Nursing) 2005.
Åsa Engström. Close relatives of critically ill persons in intensive and critical care: the experiences of close relatives and critical care nurses. (Nursing) 2006.
Anita Melander Wikman. Empowerment in living practice: mobile ICT as a tool for empowerment of elderly people in home health care. (Physiotherapy) 2007.
Carina Nilsson. Using information and communication technology to support people with serious chronic illness living at home. (Nursing) 2007.
Malin Olsson. Expressions of freedom in everyday life: the meaning of women's experiences of living with multiple sclerosis. (Nursing) 2007.
Lena Widerlund. Nya perspektiv men inarbetad praxis: en studie av utvecklingsstördas delaktighet och självbestämmande. (Health Science and Human Services) 2007.
Birgitta Lindberg. Fathers’ experiences of having an infant born prematurely. (Nursing) 2007.
Christina Harrefors. Elderly people’s perception about care and the use of assistive technology services (ATS). (Nursing) 2009.
Lisbeth Eriksson. Effects and patients' experiences of interactive video-based physiotherapy at home after shoulder joint replacement. (Physiotherapy) 2009.
Britt-Marie Wälivaara. Mobile distance-spanning technology in home care. Views and reasoning among persons in need of health care and general practitioners. (Nursing) 2009.
Anita Lindén. Vardagsteknik. Hinder och möjligheter efter förvärvad hjärnskada. (Health Science) 2009.
Ann-Louise Lövgren Engström. Användning av vardagsteknik i dagliga aktiviteter - svårigheter och strategier hos personer med förvärvad hjärnskada. (Health Science) 2010.
Malin Mattsson. Frågeformulär och patientupplevelser vid systemisk lupus erythematosus
-en metodstudie och en kvalitativ studie. (Physiotherapy) 2011.
Catharina Nordin. Patients’ experiences of patient participation prior to and within multimodal pain rehabilitation. (Physiotherapy) 2013.
Hamzah Ahmed. Relationship Between Crystal Structure and Mechanical Properties in Cocrystals and Salts of Paracetamol. (Health Science) 2014.
